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PRACTICAL TREATISE 



DISEASES OF CHILDREN. 



PRACTICAL TREATISE 



DISEASES OF CHILDREN. 






J. FORSYTH MEIGS, M.D., 

LECTURER ON THE PRACTICE OF MEDICINE IN THE PHILADELPHIA MEDICAL ASSOCIATION; FELLOW OF 

THE COLLEGE OF PHYSICIANS OF PHILADELPHIA; MEMBER OF THE ACADEMY OF NATURAL 

8CIENCES OF PHILADELPHIA, AND OF THE AMERICAN PHILOSOPHICAL SOCIETY. 



SECOND EDITION, 

REVISED AND ENLARGED. 




PHILADELPHIA: 

LINDSAY & BLAKISTON. 
185 3. 






Entered, according to Act of Congress, in the year 1853, 

BY J. FOESYTH MEIGS, M.D., 

In the Clerk's Office of the District Court for the Eastern District of Pennsylvania. 



C. SHERMAN, PRINTER, 

19 St. James Street. 



TO 

GEORGE B. WOOD, M.D., 

PRESIDENT OF THE COLLEGE OF PHYSICIANS OF PHILADELPHIA, 

PROFESSOR OF THE PRACTICE OF MEDICINE 

IN THE UNIVERSITY OF PENNSYLVANIA, 

ONE OF THE PHYSICIANS OF THE PENNSYLVANIA HOSPITAL, ETC., ETC., 

IS DEDICATED AS A TRIBUTE OF RESPECT 

FOR HIS HIGH PROFESSIONAL ATTAINMENTS 

AND EMINENT PRIVATE VIRTUES, 

AND AS A MARK OF GRATITUDE FOR HIS VALUABLE INSTRUCTIONS, 

BY HIS FORMER PUPIL, 

J. FORSYTH MEIGS. 



PREFACE 

TO THE SECOND EDITION. 



The first edition of this work formed one of a series entitled the 
" Medical Practitioner's and Student's Library." For reasons which it 
is unnecessary to relate in this place, it has been withdrawn from that 
series, and now appears as a distinct and separate publication. 

The author owes an apology to some who have been waiting for the 
second edition of this work, for its non-appearance at the time when the 
first was exhausted, now nine months since. His excuse is, simply, ex- 
cessive occupation in private practice, the demands of which have been so 
urgent as to leave him but scanty time for attention to other matters. 

The motives which induced the author of this work to undertake its 
preparation were (as stated in the preface to the first edition), the hope 
that the details of his own experience might prove of some utility, and 
the belief that a work on the diseases of children, executed upon a some- 
what different plan from those already before the profession, might not be 
an unacceptable addition to the medical literature of the country. The 
writer has, in fact, aimed to make this work more methodical and precise 
than those heretofore published in this country. He has, in narrating 
what he has himself observed, endeavored to do this with the greatest 
possible accuracy; and, where the subject has concerned one susceptible 
of numerical demonstration, he has, in most instances, employed that 
method of statement, in order to enable the reader to draw his own con- 
clusions. Whatever may be the advantages or disadvantages of the 
numerical method in medicine, it must certainly give much greater accu- 
racy and precision to medical observation than the method usually followed 



PREFACE. 



by the older writers, who merely stated their own generalizations (often, 
no doubt, loosely and carelessly drawn), instead of giving to the reader the 
facts upon which those generalizations were founded, and thus allowing 
him to judge for himself of their probable truth and correctness. 

The classification of diseases according to the systems which they affect, 
has been adopted as the most convenient. The divisions of each article 
are, with a few exceptions, those employed by the most eminent among 
recent systematic writers. In the composition of the work, the author 
has availed himself as fully as possible of the best foreign and domestic 
authorities on the diseases of children within his reach — always, however, 
endeavoring to judge what came under his notice by the knowledge derived 
from his personal experience in private practice. In this way he hopes 
that he has been able to select from the labors of others whatever is most 
important to be known in the present state of medical science, and to 
reject what seemed fallacious or useless. In order to show upon what 
basis his right of personal judgment rests, he may state that this work 
now contains the results obtained from a careful record, and, in very 
numerous instances, a daily observation, of 1180 cases that have occurred 
in his own private practice. 

The principal changes and additions that have been made in the present 
edition are the following : — An introductory essay of over thirty pages, 
upon the clinical examination of children, has been inserted, the author 
believing this to be a subject that might be treated of with advantage to 
many who have not paid that separate and distinct attention to the diseases 
of children which they demand and require. The articles on croup, bron- 
chitis, and pneumonia, have been entirely re-arranged, and in many parts 
re-written; and the results obtained from the observation of a large 
number of additional cases have been made use of. The subject of 
tracheotomy in croup has been discussed at considerable length. A 
very full article on atelectasis pulmonum, or imperfect expansion of the 
lungs, has been added, and the new doctrines in regard to atelectasia have 
been applied in the articles on bronchitis and pneumonia. The article on 
scarlet fever has been almost re-written, and the results of a little over 
one hundred new cases have been added to those contained in the first 
edition. This subject has, indeed, been very fully treated of; for the 
disease has been so rife and so fatal in this country of latter years, as to 



PREFACE. XI 

give it much greater importance than formerly. A mode of classification 
of the disease, different from that in general use, and one which will make 
it, the author thinks, more readily understood, has been employed. The 
article on measles has also been very much added to. Lastly, there will 
be found somewhat over a hundred pages of new matter on the diseases 
of the skin. In the consideration of these latter affections, the author 
has endeavored to be full and thorough, without being diffuse or prolix. 

To conclude, the author has merely to say to any who may chance to 
inquire why he has not furnished articles on some subjects untouched 
upon in the present volume, that the reason is solely the want of time 
and opportunity to make use of the materials he has collected. Should 
the work have the good fortune to pass into another edition, he hopes and 
expects to fill up the omissions of the present one. 

Philadelphia, May, 1853. 



TABLE OF CONTENTS. 



PAGK 

Preface, ......... 5 

Introductory Essay, . . . . . . . 17 

CLASS I. 
DISEASES OF THE RESPIRATORY ORGANS. 

CHAPTER I. 

DISEASES OF THE UPPER AIR PASSAGES. 
SECTION I. 

DISEASES OF THE NASAL PASSAGES. 

Article I. — Coryza, ........ 53 

SECTION II. 

DISEASES OF THE LARYNX. 

General Remarks, ........ 60 

Article I. — Simple laryngitis without spasm, . . . . .61 

" II. — Spasmodic simple laryngitis, ..... 65 

" III. — Pseudo-membranous laryngitis, . . . . .83 

CHAPTER II. 

DISEASES OF THE LUNGS AND PLEURA. 

General Remarks, . . . . . . . . 114 

Article I. — Atelectasis pulmonum, . . . . . .114 

' : II. — Pneumonia, . . . . . . . 139 

" HI- — Bronchitis, . . . . . . .175 

" IV.— Pleurisy, ....... 197 

" V. — Hooping-cough, . . . . . . .211 



XIV CONTENTS. 

CLASS II. 
DISEASES OF THE DIGESTIVE ORGANS. 

CHAPTER I. 

DISEASES OP THE MOUTH. 

PAdE 

Article I. — Simple or erythematous stomatitis, .... 229 

« II— Aphtha-, 230 

" III. — Ulcerative or ulcero-membranous stomatitis, . . . 233 

« IV. — Gangrene of the mouth, . . . . . .238 

» V.— Thrush, 249 

CHAPTER II. 

DISEASES OF THE THROAT. 

Article I. — Simple or erythematous pharyngitis, . . . .265 

" II. — Pseudo-membranous pharyngitis, . . . . 271 

CHAPTER III. 

DISEASES OF THE STOMACH AND INTESTINES. 
General Remarks, . . . . . . . .280 

SECTION I. 

FUNCTIONAL DISEASES OF THE STOMACH AND INTESTINES. 

Article I. — Indigestion, . . . . . . 283 

" II. — Simple Diarrhoea, . . . . . . .294 

SECTION II. 

DISEASES OF THE STOMACH AND INTESTINES, ATTENDED WITH APPRECIABLE 
ANATOMICAL ALTERATIONS. 

Article I. — Gastritis, ....... 304 

" II.— Entero-colitis, . . . . . . .312 

" III.— Cholera infantum, ...... 339 

,! IV. — Dysentery, . . . . . . .365 

CLASS III. 

DISEASES OF THE NERVOUS SYSTEM. 

General Remarks, ........ 370 

CHAPTER I. 

DISEASES OF THE NERVOUS SYSTEM ATTENDED WITH APPRECIABLE 
ANATOMICAL ALTERATIONS. 

Article I. — Tubercular meningitis, . . . . . 371 

" II. — Simple meningitis, ...... 39S 



CONTENTS. 



XV 



Article III. — Acute hydrocephalus, 
" IV. — Cerebral congestion, 
" V. — Cerebral hemorrhage, 



PAGE 

407 
411 
415 



CHAPTER II. 

NEUROSES, OR DISEASES OF THE NERVOUS SYSTEM, UNATTENDED 
WITH APPRECIABLE ANATOMICAL ALTERATIONS. 



Article I. — General convulsions or eclampsia, 
" II. — Laryngismus stridulus, 
" III. — Contraction with rigidity, 
" IV.— Chorea, 



425 
443 
459 
470 



CLASS IV. 
ERUPTIVE FEVERS. 



Article I. — Scarlet fever or scarlatina, 
" II. — Measles, rubeola or morbilli 
" III. — Variola or small-pox, 
" IV. — Vaccine disease. 
" V. — Varicella, . 



482 
546 
570 
587 

597 



CLASS V. 
DISEASES OF THE SKIN. 



Introductory Remarks, 



Article I. — Erythema, 
II. — Erysipelas, 
III. — Roseola, 
IV. — Urticaria, 



CHAPTER I. 

RASHES. 



601 



601 
607 
615 
619 



Article I. — Eczema, 
II.— Herpes, 
III. — Scabies. 



CHAPTER II. 

VESICLES. 



CHAPTER III. 

BULLiE. 



Article I. — Pemphigus or Pompholyx. 
i; II. — Rupia, . 



623 
629 
636 



640 
642 



XVI 



CONTENTS. 



Article I. — Ecthyma, 
" II. — Impetigo, 



Article I. — Strophulus, 
" II. — Lichen, 
" III. — Prurigo, 



Squama?, 



CHAPTER IV. 

PUSTULES. 



CHAPTER V. 

PAPULES. 



CHAPTER VI. 



PAGB 

646 
648 



663 
665 
666 



668 



CHAPTER VII. 

DISEASES OF THE SKIN NOT CLASSIFIED AMONGST THE PRECEDING. 

Article I. — Favus, ....... 670 

II. — Trichosis furfuracea or ringworm of the scalp, . . . 678 



CLASS VI. 

WORMS IN THE ALIMENTARY CANAL. 



General Remarks, . 
Article I. — Ascaris lumbricoides, 
" II. — Ascaris vermicularis, . 



683 
687 
700 



PRACTICAL TREATISE 



DISEASES OF CHILDREN, 



INTRODUCTORY ESSAY. 

ON THE CLINICAL EXAMINATION OF CHILDREN. 

The examination of sick children, and particularly that of young infants, 
with a view to the diagnosis of their diseases, cannot be made in the same 
manner precisely, or by the same steps, as are habitually employed in the 
case of adult patients. That this assertion is true will be denied by none 
who have had any experience in the treatment of the diseases of the two 
ages, by none who will reflect for a moment on the great differences in 
the expressions of the various organs in early and adult life, and by 
none who are acquainted with the opinions of distinguished writers upon 
children's diseases. It is proper and useful, therefore, to preface a prac- 
tical work on the diseases of children, with a sketch or plan of the best 
method to be pursued in forming a diagnosis of those diseases, and with 
remarks upon the physiological characters which distinguish the organiza- 
tion of early life from that of mature years. 

The difficulties that beset the path of the practitioner in his clinical 
examination of children are so great that he who has not been prepared 
by preliminary study to surmount those obstacles, will find it a most 
uncertain and dubious task to unravel the history and nature of any case 
that may be set before him. The helpless silence of the infant, — the 
wilful stillness, or the loose and inconsistent answers of the older child, 
which lead astray the mind rather than guide it to true results, — the agi- 
tation and fright produced by the examination, rendering it impossible at 
times to ascertain the real state of the different functions of the economy, 
— and, lastly, the difficulty of obtaining accurate and reliable accounts 

2 



18 INTRODUCTORY ESSAY. 

from the attendants of the history of the case, all combine to make the 
duty of the physician most perplexing, and, unless he be gifted with a 
large share of patient and philosophic calmness, most irksome and trying 
to the temper. So great, indeed, are the difficulties encountered by some 
practitioners, who enter upon this branch of the practice of medicine 
without proper preliminary preparation, that they never overcome them ; 
but, to use the words of Dr. West, "grow satisfied with their ignorance, 
and will then, with the greatest gravity, assure you that the attempt to 
understand these affections is useless." That it is possible, however, to 
overcome, in great measure, these obstacles, and to arrive at a correct 
diagnosis in nearly all cases, is quite as true as that these obstacles really 
exist. But in order to do this, the physician must first be aware that 
difficulties exist, and must have formed in his mind some plan or method 
by which to surmount or elude them. 

Before proceeding to show what is the best method of examining or 
exploring disease in children, I must state that my remarks apply chiefly 
to infants and very young subjects; for, after the age of eight and ten 
years, the physical and intellectual development have progressed to such 
a point as to render the method of diagnosis nearly the same as that 
employed in adults. 

The chief causes which render the diagnosis of disease in young children 
difficult, are the absence of the faculty of speech, and the violent agitation 
generally caused by the examination, which prevents a proper appreciation 
of the state of certain organs and functions. 

It is easy to understand how much our means of diagnosis are restricted 
by the absence of the faculty of speech. How many symptoms are there 
in the case of adults with which we become acquainted only through the 
patient's own account of his sensations ; and, consequently, of how many 
must we be deprived in children by the absence of this account? It 
might, indeed, at first view, seem impossible to detect the nature of the 
sickness without the assistance of this means, so greatly do we depend 
upon it in our examinations of adults. Nevertheless, we shall find our- 
selves enabled, by an attentive consideration of other resources in the 
child, by a close study of its physiognomical expression, its decubitus, the 
nature of its cry, and by the most rigidly careful physical examination, to 
form our conclusions with almost as great a degree of precision as in older 
patients. 

The other causes of difficulty, — the violent disturbance, both physical 
and moral, of the child, its fright, agitation, and cries, — constitute, when 
they are present in a high degree, much greater embarrassments than the 
want of speech. To overcome these, the physician must use all his skill, 
tact, and patience ; for, unless they can be avoided by art, or overcome 






METHOD OF DIAGNOSIS. 19 

by soothing and gentle persuasion, he can learn but little that will be of 
essential service to him in making up his opinion. He can neither read 
the countenance of the little patient, nor judge by its attitudes or decu- 
bitus of the state of the various organs, whether internal or external ; he 
will be unable to ascertain the rate, force, or regularity of the circulatory 
or respiratory functions ; he cannot, to any useful purpose, examine the 
abdomen, to learn whether it be tender on pressure, or whether its con- 
tained organs be in their natural condition as to size and position ; and 
lastly, he will find that the physical exploration of the lungs and heart, 
by auscultation and percussion, yield him at best only imperfect results. 

To avoid the difficulties just detailed, it is always useful, if not abso- 
lutely necessary, to conduct certain portions of the examination whilst the 
child is calm and quiet, and certain others whilst it is disturbed and 
agitated. This distinction of the examination into two periods, or stages, 
is one of the utmost importance in a practical point of view, and should 
never be forgotten by the physician during his clinical observation of the 
various symptoms the patient may present. 

By the period of calm is meant a condition of total quiescence, in which 
the child is undisturbed either by internal or external causes of irritation. 
This condition is best found in the state of sleep. If this cannot be 
obtained, the one most nearly approaching to it is that which exists 
during the act of nursing, or which follows that act. The luxurious ease 
that follows a full meal, almost always causes the infant to fall into a 
gentle and languid slumber, during which it will allow a careful examina- 
tion upon many points without agitation. If possible, therefore, the 
physician should always see the child when asleep, and if the mother or 
nurse propose, on the occasion of his visit, to hurry up stairs to prepare 
the child, or to bring it down into the parlor or lower room, he should 
ask, as a favor, that he may see it if possible asleep. 

If, in spite of having just been nursed, the child be awake and fretting, 
and when, also, it is more advanced in age, we should endeavour, by the 
attraction of toys, by gentle and soothing words and manners, by fondling, 
or by having it carried about the room, to get it quiet. 

Before proceeding to a consideration of the particular means by which 
we are to judge of the state of health or sickness of young subjects, it is 
proper to call attention to the great importance of a careful examination 
of the attendants, in regard to the history of the case, previous to and 
between the medical visits. In the instance of children, their inability to 
describe their own symptoms compels us to depend entirely upon the 
mother or nurse for all detail of the case previous to our first visit, and 
for all accounts of what may have happened between two subsequent ones. 
It is, therefore, extremely important that this part of the examination 



20 INTRODUCTORY ESSAY. 

should be conducted with every care and caution. Very much that is useful 
may be learned from it, if it be well managed. A great deal of skill and 
art are required in putting the questions, and in sifting the evidence thus 
collected. We should always bear in mind the character of the persons 
questioned. Much depends upon their education, and much more on their 
natural powers of observation, and manner of relating what they may have 
seen. The degree of credence to be attached to their answers must rest 
upon their probable intelligence. Nurses and mothers will often give 
accounts of their charges which must be received with large allowance, and 
even in some few instances with disbelief. I would, however, in this 
place, most earnestly caution the young practitioner of medicine to be 
very careful not to misbelieve, or even mistrust, without well-poised 
reasons, the account of a sick child given by a mother ; for though a 
foolish, weak woman will often give a false or exaggerated statement of 
the symptoms of her child, an observant and intelligent, and sometimes 
a foolish and weak one, when guided by maternal instinct, will detect 
variations from the healthful condition of a child, which may entirely 
escape the search of the most acute and rigorous medical observer. A 
mother may perceive a change in the expression of the face, in the manner 
of the muscular movements, in the temper or conduct of her child, which 
shall fail to attract the attention of the practitioner ; or it may be that 
the symptom which has caused the parent to take alarm occurs only 
during the absence of the physician. The medical attendant ought, for 
these reasons, to listen patiently and kindly to whatever the mother or 
nurse may have to say, and if unable to detect immediately what they 
assert they have seen, let him not determine at once that there has been 
a mistake, that their anxiety has deceived them ; but let him examine 
the patient yet again, and more carefully, or let him pay another visit to 
learn whether the symptom or symptoms continue, or have occurred 
again. My own rule, in a doubtful case, is to listen with religious atten- 
tion to the mother, and unless she be far beneath the average of human 
intelligence, my opinion as to the fact of some deviation from the ordinary 
health of the child is considerably influenced by what she tells me. 

The inquiry in regard to the history of the case, previous to the first 
visit of the physician, should bear particularly upon the causes of the 
sickness, its precise moment and mode of attack, and its course and symp- 
toms up to the present time. The most important points to be considered 
in connexion with these objects, are the health of the parents, including 
their ordinary health, or their habitual diseases, and the causes "and 
periods of their death, if they are not living ; and the state of health of 
the child at the moment of birth and since. The hygienic conditions in 
which the patient has been placed ought always to be investigated : the 



DIAGNOSIS OF ANTECEDENTS. 21 

place of habitation; the kind of house, and whether a large well-venti- 
lated room or a small, narrow, and close one; the clothing; the food; 
and lastly, whether the infant has been suckled, or brought up on arti- 
ficial diet. The state of the health just anterior to the attack ought 
always to be examined into. Has it been good and strong, or feeble and 
delicate? If delicate, what diseases? If the approach of any of the 
eruptive fevers be suspected from the character of the symptoms, the 
question as to whether the child has previously had measles or scarlet 
fever, or has been vaccinated or had variola, should always be asked. 

It is next necessary to fix as accurately as possible, the precise period 
of the onset of the sickness. If the question, " When was the child 
taken sick?" be asked, as it usually is, the answer will be, "Oh, 
several days ago," or, " I don't recollect exactly — I think yesterday, or the 
day before," or some such loose answer. The best way to learn the exact 
period in a recent case, is to go back, day by day, or else to inquire as to 
some particular day. We may ask, was the child quite well day before 
yesterday; was it well last Sunday? did it play and amuse itself? was it 
as gay and good-tempered as usual yesterday, or the day before, or the day 
before that ? Did it sleep well night before last, or the night before that ? 
A sick child never scarcely sleeps well at night, and very often we may 
learn by close inquiry into this particular, the exact time at which the 
attack began. In this way, by forcing the attendant to tax her memory, 
and to go minutely over the events of the several days previous, we shall 
nearly always succeed in fixing very precisely, the moment of onset. 

Having determined these points, we should proceed to inquire in 
regard to the course of the disease prior to the first visit. This is to be 
done only by patient and repeated questioning. The questions must be 
so framed as to elicit free and unbiassed answers. They should be general, 
and not leading. Lastly, we are to inquire into the treatment of the case 
up to the present time. 

It is best that all these interrogatories should be made previous to 
seeing the child, in some other room than the nursery, in order to avoid 
the risk of alarming the child by the presence, during an unnecessary 
length of time, of a stranger. If, however, the child be well acquainted 
with the physician, it matters not where the inquiries are made. 

Having now obtained from the attendants all the information they can 
give in regard to the history and nature of the case, the physician must 
proceed to the personal examination of the patient in order to determine, 
by his own observation, the exact nature of the sickness, and the treatment 
that it may require. 

The most important points to be attended to during the clinical 
examination, are the countenance or facies, noting its expression, colora- 



22 INTRODUCTORY ESSAY. 

tion, the presence or absence of furrows and wrinkles from pain, from 
emaciation, or from disordered muscular action, the appearances presented 
by the nasal orifices, aud especially by the alee nasi, and the characters ex- 
hibited by the mouth ; the sleep ; the cry ; the state of embonpoint or 
emaciation; the condition of the skin as to coloration, temperature, 
moisture or dryness, the presence of swellings of any kind, such as those 
produced by dropsy or by affections of the joints, and the existence of 
eruptions ; the pulse ; impulse of the heart ; the respiration ; the signs 
furnished by the state of the mouth and throat, and by the disposition 
towards and power of sucking, or by the manner in which drinks are 
taken ; and lastly, the state of the abdomen. 

The Countenance. — The countenance of a young and healthy infant, 
who is sleeping or perfectly quiet, wears no expression except that of 
comfort and content. It is composed and still; no movement disturbs 
its innocent tranquillity, unless, perhaps, some gentle smile light it up 
from time to time, when we might well believe the happy superstition of 
the fond mother, who will tell us that angels are whispering it. In 
sickness, even when slight, the countenance soon loses this expressionless 
character. In all acute disorders the alteration is very great, such indeed 
as to strike the most careless and inexperienced observer. The features 
become contracted, furrows and wrinkles appear about the forehead, the 
nostrils are dilated, or pinched and thin, and the mouth becomes drawn 
and rigid. The extent of the change is generally in proportion to the 
severity of the attack. The part of the face most altered will depend 
very much upon the particular system of organs implicated in the 
disease. 

Some authors have endeavored to show that different diseases give to 
the physiognomy certain peculiar and characteristic expressions. This is 
true only to a certain extent. Thus, the facies is very different in abdo- 
minal from that which exists in thoracic or cerebral diseases ; but though 
it is generally easy for a practised observer to distinguish by the facies 
alone between a cerebral and a thoracic disorder, it is quite impossible for 
him to distinguish between any two cerebral, thoracic, or abdominal 
affections. The particular changes impressed upon the face by different 
diseases cannot, however, be discussed in this place, but must be con- 
sidered in the separate articles upon each disease. Here, it can only be 
stated in general terms, that, in diseases of the brain, the upper part of 
the face, the forehead, and the eyes are chiefly affected ; that in diseases 
of the thoracic organs, the middle portion of the face, and especially the 
nostrils; while in those of the digestive organs, the lower part of the 
face, the mouth, and lips, are the parts which undergo the greatest 
changes in their expression. 






SIGNS FROM THE COUNTENANCE. 23 

Pain may almost always be detected by the expression of the face. It 
gives to the countenance various shades of expression, according to its 
degree of severity, and its permanency or recurrence at intervals. Pain 
in the head is said, by Dr. M. Hall, to produce a contracted brow, pain 
in the belly to occasion an elevation in the upper lip, whilst pain in the 
chest is chiefly denoted by sharpness of the nostrils. I doubt, however, 
whether pain in any particular organ imparts an expression to one part of 
the face rather than to another, for indeed pain in any part of the body, 
whether the head, chest, abdomen, or limbs, gives rise to a contraction of 
all the features. Not one part of the face alone, but the forehead, mouth, 
nose, and the whole face become changed in expression and contracted, 
when there is severe pain in any part of the body, so that I deem it 
impossible from the expression caused by pain alone to determine where 
the painful sensation may be seated. The countenance merely tells us 
there is pain, but not where it is located. The painful expression will be 
permanent or occasional as the pain itself is constant or only paroxysmal. 

The coloration of the face becomes often an important means of diag- 
nosis. In all the fevers, phlegmasiae, and diseases of general excitement, 
the face will be more or less suffused and red, unless the attack be so 
severe as to occasion a violent shock to the nervous system, in which 
event the countenance instead of being suffused, is paler than natural. 
In such cases the face becomes of a dead white, all traces of red disap- 
pear, and the skin at the same time has often a slightly shining or 
varnished appearance. I have not unfrequently observed this symptom in 
pneumonia and bronchitis, and also in the latter stages of true croup. It 
is a very striking phenomenon, and one which usually portends great 
danger. 

In chronic cases of all kinds in which the hematosic and nutritive 
functions are enfeebled, the face assumes a pallid and waxen hue, which 
is very characteristic. In the various digestive ailments it becomes 
icterode or sallow, and in affections of the liver more or less yellow. 
Lastly, in certain diseases and malformations of the heart, it becomes 
bluish or livid, constituting one of the most important signs of what is 
called morbus coeruleus, blue disease, or cyanosis. 

In reading the countenance of a sick child, the practitioner should 
always notice the play of the nostrils, since this reveals, to a certain 
extent, the state of the lungs. In pneumonia, bronchitis, and pleurisy, 
the movements of the alae nasi become rapid and energetic, expressing, by 
the degree of their violence and extent, the amount of embarrassment 
under which the respiratory function is laboring. 

The nostrils and nasal passages should always be examined also to 
ascertain the presence of mucous or purulent secretions, or of pseudo- 



24 INTRODUCTORY ESSAY. 

membranous deposits, since these fluids or their inspissated products 
interfere more or less with the free passage of air through those canals. 

Of the Sleep. — Much useful information as to the state of health of 
infants and children may be learned from a careful consideration of the 
various phenomena connected with their sleep. Of this I am fully con- 
vinced, from somewhat long and patient observation. We cannot ascer- 
tain indeed the nature of the disease under which the child may be 
laboring, but we can detect, with very great certainty, the existence of a 
deviation from health. I know of few more certain means of fixing the 
period at which any attack of illness may have begun, than by inquiring 
at what time the child began to have restless or broken sleep, or 
insomnia. 

A perfectly healthy infant, within the month, who is suckled at an 
abundant and wholesome breast, will usually sleep twenty out of the 
twenty-four hours, waking to nurse every two or three hours during the 
day, and twice or three times during the period of darkness. After the 
age of two or three months, the child is much more wakeful during the 
day, though it will still take a nap of two or three hours in the morning, 
and a shorter one in the afternoon, while it will sleep from early evening 
until the following morning, waking but once or twice to suck. Indeed, 
many perfectly healthy infants, of between three and six or seven months 
of age, sleep without waking from nine Or ten o'clock in the evening, 
until six the next morning. After the latter age, the sleep is seldom so 
unbroken, the child begins to undergo the first considerable trial to its 
health, dentition, and it is rendered thereby more or less ailing and 
irritable, and consequently restless and troublesome at night. 

Children who have passed through the epoch of dentition, and who are 
perfectly well, usually go to sleep soon after being put to bed, and never 
wake again until the following morning. Not only so, but they sleep 
soundly and quietly, without being disturbed by slight sounds, and 
without tossing or turning much in their sleep. 

In healthful sleep the whole appearance of the child, its expression of 
countenance, its attitude, and its breathing, are full of the most perfect 
and beautiful ease and tranquillity. Nothing can be more suggestive of 
the comfort and well-being that naturally attend upon health, than the 
perfect composure and graceful postures exhibited by a hearty child 
during profound sleep. 

It needs, however, but a slight disturbance of the health of a child to 
break in upon its ordinarily calm and peaceful sleep, and to render this rest- 
less, fitful, and interrupted by startings, cries, or dreams, or insufficient. 
The most trifling irritations, as the pressure of a tooth against the gum, the 
presence in the digestive canal of a little imperfectly digested food, or of one, 



SIGNS FROM THE SLEEP — CRY. 25 

two, or three lumbricoides, or the slightest fever from any cause, are suffi- 
cient to produce this effect, and hence it is that the character of the sleep 
will often become to a watchful practitioner the first sign of disorder held 
out by nature. 

The degree of disturbance of this function will vary with the nature 
and severity of the disturbing cause. When slight the child will continue 
to sleep throughout the ordinary period, but the sleep will be somewhat 
uneasy. The countenance will be disturbed. There will be contractions 
of the brow, and momentary workings of the features will express the 
perception of some unhealthful sensation. Often the child will toss and 
turn, and change its position more frequently than natural. Sometimes 
it will cry out, and appear distressed by some dream or painful sensation. 
"When the cause of disturbance is more serious, the sleep is more broken, 
the child wakes often, and lies awake for a longer or shorter time, and it 
becomes very difficult to lull it to sleep again. Or it has painful dreams 
or nightmare, causing it to scream and struggle in sleep, and then to 
wake in the most violent affright. In severe instances it becomes almost 
sleepless. I have very often known teething children not to sleep more 
than half as much as in health, and to wear out, by the long continuance 
of this sleeplessness, the patience and even the health of their attendants. 
In some instances they will no longer sleep in the bed or crib, and the 
nurse is obliged to get up and walk with them, or soothe them by the 
movement of a rocking-chair or cradle. In other cases, the derange- 
ment of the health is shown by grinding of the teeth, and by the most 
violent tossing and tumbling about the bed. I have frequently seen a 
child lying with its head where its feet should be, or across the bed, and 
with all the coverings thrown off, in spite of the most careful arrangement 
of the bed-clothes. 

These various disturbances are therefore signs of some alteration in the 
health of the child. They do not lead to an appreciation of the precise 
nature of that alteration, but they are invaluable as affording indications 
of the existence of some morbid condition of the economy. Yery often, 
as above stated, they are the first symptoms of the approach of some more 
or less serious sickness, and as such will often enable us to determine, 
with much precision, the moment of onset of the attack. 

The Cry. — Crying is one of the modes of expression of the child. 
Indeed, this, with the expression of the face, are, according to M. Billard, 
the only means of expression with which nature has endowed the young 
infant. This is, however, scarcely correct, since we may also class 
amongst its means of expression the various spontaneous muscular 
movements indicative of uneasiness, or of pain, or pleasure ; the manner 
in which it drinks or sucks, whether eagerly and with appetite, or Ian- 



26 INTRODUCTORY ESSAY. 

guidly, or carelessly, or not at all ; the enjoyment it receives from 
pleasant sounds ; and the evident delight it takes in regarding the light. 
Nevertheless, the cry and the expression of the countenance are the 
two means on which the physician must chiefly rely for early information 
of the occurrence of sickness in the young infant. These are the trusty 
guards of nature. By them she first gives notice of the approach of 
danger, and then measures the amount of mischief that may have been 
done. 

The cry which a child utters during sleep, or even when awake, and 
when nothing has been done to excite or disturb it, is always indicative of 
some uneasiness. If the cry be caused by pain, or by any considerable 
disturbance, it will be accompanied by certain contractions of the features 
and movements of the body and limbs, which will still more strikingly 
show that the pain, or other exciting cause, is of a serious nature. Violent 
and obstinate crying is almost always caused by severe pain, — such as the 
pain of earache. Indeed, obstinate and long-continued crying, lasting for 
hours, is rarely met with except from one of two causes, earache or 
hunger. The cry of earache is often incessant and unappeasable, the pain 
being generally constant, and not paroxysmal, as are most other pains. 
It is to be silenced only by the application of remedies to the ear, or by 
the internal administration of opiates. I have known an infant, three 
months old, to scream with earache for two days and nights, with only 
short lulls of a few hours when brought under the influence of large doses 
of laudanum. As soon as the ear began to discharge, the cry ceased. I 
am constantly called to see infants and young children who have been 
crying most violently for hours, and who are thought to have colic, or to 
have hurt themselves, but who are, in fact, tortured with that most violent of 
all pains, earache. I have met with few instances in which such severe 
and constant crying has depended on other causes ; for, though children 
scream violently and obstinately from hunger and thirst, they may always 
be quieted by the supply of either want, whilst in earache the infant 
generally refuses the breast, or takes it only for a few instants, and then 
lets go to resume his almost automatic scream. 

In not a few instances I have known infants to cry very often in the 
day and night, and sometimes very obstinately, too, from hunger. In such 
cases the child is thought to have colic, and as it is not unfrequently costive, 
it is dosed with cathartics, carminatives, and opiates ; or, it is being brought 
up partially or wholly upon artificial diet, and as a consequence, has some 
disorder of the bowels, which is thought to require other kinds of medica- 
ments for its relief. When the stools are natural in appearance, or 
merely costive, and when the child does not labor under flatulence, it is 
easy, by careful questioning of the mother, to discern whether she has 



! 



SIGNS FROM THE CRY. 27 

milk enough, and by examination of the size and weight of the child, to 
judge whether growth and nutrition go on in their proper ratio ; and if it 
be found that the mother is a poor nurse, and that the development of 
the ehild is slow and imperfect, we should at once direct an additional 
supply of nourishment, and the suspension of all mere drugs. I have 
often been surprised and delighted to find how soon, under the new treat- 
ment, the child becomes placid and comfortable, how well and how long 
it sleeps, and at what a rapid rate it developes its form and size. So, 
when the circumstances above referred to coincide with a somewhat dis- 
ordered state of the bowels, we should first choose for the child the diet 
most appropriate to its age and state of health, and then, if after inquiry 
it appears that the whole quantity taken in the twenty-four hours is 
below the proper standard, the amount allowed must be augmented. 

The crying occasioned by pain in the head, by the pain which accom- 
panies pneumonia or pleurisy, or that which is attendant upon abdominal 
inflammations is never scarcely constant, though it may be violent while 
it lasts. Pain in the head usually causes a sudden and sharp cry or 
shriek, which is over as soon almost as heard, and which has been called 
the hydrencephalic cry. The pain of pneumonia, which, it should be 
remarked, is not unfrequently absent, or so slight as not to be noticed, 
commonly occasions crying only during coughing, and for a short time 
after, and is accompanied by distortion or grimacing of the features. In 
pleurisy, again, the cry is also heard generally at the moment of cough- 
ing, but it is produced also by the act of moving the child, and by pres- 
sure on the affected side. It is commonly much louder, shriller, and 
indicative of greater suffering than in pneumonia, and in some cases that 
I have seen, has been very frequent and difficult to appease. 

The cry of intestinal pain may almost always be recognised by the 
fact that it takes place just before or after a stool, that it is accompanied 
by wriggling and twisting movements of the trunk, and especially of the 
pelvis, or in very young infants, by its coincidence with more or less 
flatulence, which is revealed by a tympanitic condition of the abdomen, 
and by frequent regurgitations of gas. 

Children not unfrequently cry much and very obstinately from mere 
fretfulness and general distress or malaise. This kind of crying may be 
recognised by its peculiar tone, which is short, sharp, and, so to speak, 
moral. It is a fret rather than a scream ; it is occasioned by the least 
disturbance offered to the child, by the attempt to move it, to dress it, to 
attend to any of its wants, even to look at or notice it ) it is moreover 
possible, generally, to still such a cry by soothing treatment, or by the 
endeavor to amuse the little thing with toys. 

Lastly, a child will sometimes attempt to cry, but is unable to utter 



28 INTRODUCTORY ESSAY. 

any or only a very faint sound. This depends commonly upon some 
laryngeal impediment, but may be also the result of pure exhaustion ; 
there is not sufficient strength to sound a cry. 

The cry of the young child has been divided by M. Billard into the 
cry proper and the reprise or return, and inasmuch as these two portions 
of the cry are differently affected in different diseased conditions, it is 
important that we should be aware of their existence, and of the effects 
produced upon their manifestations by disease. 

The cry proper is produced during the act of expiration, while the 
reprise occurs during inspiration. The cry proper is sonorous and pro- 
longed, the reprise is much shorter and sharper. The reprise is feeble 
in young infants, and becomes stronger as they advance in age. In 
different states of health the mode of crying will vary to a considerable 
extent. The cry may exist alone, or in combination with the reprise, or 
again the reprise only may be heard, whilst the cry is from some cause 
suppressed. The distinction between the two portions of the cry may 
always be distinctly perceived in a child who is crying violently from 
any recent cause, whether ill-temper, fright, or pain, unless one or other 
has been suppressed by some morbid condition which interferes with the 
perfect performance of the vocal function. After a time, however, when 
the infant has become fatigued with its efforts, the cry proper ceases in 
part, and we have only the reprise, which is heard from time to time 
between the sobs. According to M. Valleix, it is the reprise which 
becomes enfeebled and disappears first, whenever one portion only of the 
cry is heard. Towards the fatal termination of all diseases, the reprise 
ceases more or less completely, and the cry assumes a peculiar moaning 
or murmuring, which must be familiar to all who have been much in the 
sick rooms of children. 

With a remark upon the condition of the lachrymal secretion in dis- 
ease, I shall conclude this division of the subject. 

The infant does not begin to secrete tears until towards the third or 
fourth month, and of course this function can furnish no sign previous to 
that time. After that period, however, the suppression of this secretion 
becomes, according to M. Trousseau, a valuable aid to prognosis, as this 
suppression occurs generally in all dangerous acute diseases. The occur- 
rence of this symptom in any acute case should be looked upon, therefore, 
as one of dangerous augury, while the continuance of the secretion, or its 
reappearance after it has been suppressed, is, on the contrary, a highly 
favorable omen. 

General Appearance of the Child; Development; Embon- 
point ; State of the Skin, etc. — While occupied in hearing the account 
of the sickness given by the mother or attendants, and even while asking 



GENERAL APPEARANCE — DE VELOPEME NT, ETC. 29 

questions in regard to the present state of the patient, the physician may 
learn a great deal that is useful, by an attentive study of the general 
appearance of the child as it lies before him. He should remark its size 
and development, its state of embonpoint or emaciation, its decubitus 
and gestures, the color, temperature, and dryness or humidity of the skin, 
and the presence of eruptions or swellings of any kind. Having watched 
narrowly these and various matters during the early part of the examina- 
tion, he should proceed personally to inspect the whole external surface 
by touch and sight, in order to acquire precise and accurate information 
upon these various points. 

A child who has been healthy and well since its birth ought to have 
attained a certain average size and development at a certain age. If, on 
the contrary, it be much below that average size, if at three months it 
look like a new-born child, or at a year old like one of six months, it is 
very clear that something has acted to determine such slow and insuffi- 
cient growth, and it becomes the business of the practitioner to discover 
what the impeding cause has been. Not only ought a child to have a 
certain size and stature, but it should also be possessed of a certain 
degree of embonpoint. A perfectly healthy young child, one under four 
years of age, usually presents a much greater fuluess and rotundity of 
the trunk and limbs than does the adult. Its tissues are firm and solid, 
its surface of a cool and pleasant temperature, its coloration of a clear 
and exquisite white, finely tempered with a faint rosy tint in a warm 
atmosphere, or slightly marbled with light bluish spots in a colder air. 
Few marks more certainly indicate a healthful temper of the constitution 
than the clear and exquisitely-tinted pink color of the palmar and 
plantar surfaces of the hands and feet of a young child. Nothing, in- 
deed, can be more beautiful or perfect in shape or contour than the figure 
of a fine hearty young child, nothing more pleasing to the eye than its 
delicate but vivid coloring, and nothing more expressive of the fulness of 
health and vitality than its whole appearance. 

When, therefore, instead of those marks of a pure and active state of 
the health, we meet with stunted growth, emaciation, soft and flaccid 
tissues, sallow and dingy tint of the cutaneous surface, pallid or bluish 
feet and hands, weak and listless movements, how easy the conclusion 
that some jarring agent is at work to hinder and obstruct the machinery 
of life. 

In acute diseases emaciation takes place rapidly, but the tissues still 
retain some degree of elasticity and firmness. In chronic diseases the 
emaciation is of course slower, but it is more complete, so that, in some 
instances, the frame seems to consist merely of the bones wrapped round 
with a dark and unhealthy skin. The tissues beneath the skin, the 



30 INTRODUCTORY ESSAY. 

cellular, adipose, and muscular, are in great part absorbed, and the skin 
falls into wrinkles and irregularities on the least movement of the child. 
In some cases of disease, and particularly in those of the abdomen, the 
derm loses almost entirely its elasticity, so that when pinched into a fold 
by the fingers, it retains for some time the form that has been given 
to it. 

The decubitus and gestures of the child ought to be noticed. Healthy 
children are, when awake, almost always in motion. Those who have 
attained the habit of walking are tempted to active exercise by their 
various plays and amusements. Infants, though they sleep much more than 
older children, are also when awake constantly moving their limbs ; they 
are seldom still. When asleep they rest quietly and comfortably, generally 
upon the side, though often upon the back. How different when the 
child is laboring under disease of any kind. The disposition to move- 
ment is gone ; the older child insists upon lying on the lap, or in the 
cradle or bed, and the infant is to be soothed of its crying and fretfulness 
only by rocking and fondling in the arms. Instead of the free and spon- 
taneous movements of health, we now see only the sudden, impatient, and 
causeless tossing on the bed or lap, or the constant .changing of posi- 
tion, with fretting or complaining, which constitute the agitation of sick- 
ness ) or else the slow, languid, and hesitating movements of weakness or 
prostration ; or lastly, the stillness and immobility of stupor or of coma. 

There is nothing peculiar about the decubitus of pneumonia or bronchi- 
tis except when there is severe dyspnoea, in which case the child, if old 
enough to select its own position, lies high upon the pillows, while those 
who are younger evidently prefer to rest on the lap of the nurse, with the 
trunk and head supported in her arms, and express by crying and agita- 
tion, their discomfort and uneasiness, when placed in the recumbent posi- 
tion in the lap, or in the cradle or crib. I have seen several young chil- 
dren affected with severe bronchitis or pneumonia, who have preferred to 
any other position that of being held in the nurse's arms, with the front of 
the chest placed against her chest, and the head hanging over her shoul- 
der. When the dyspnoea is so severe as to produce, by slow degrees, a 
partial asphyxia and consequent dulness of perceptivity, the child becomes 
soporous or comatose, and lies usually upon the back, as in diseases 
attended with prostration of strength. 

In pleurisy and peritonitis the decubitus is usually dorsal, and the child 
dislikes to be moved or nursed, often crying violently when touched or 
disturbed. 

In intestinal inflammations the young patient is usually excessively rest- 
less at first, and very fretful, unless the attack be grave and threatening, 
when it often lies still for a time from the prostration of strength which 
attends violent attacks, but becomes restless, turns and twists in the 






DECUBITUS — MUSCULAR MOVEMENTS. 31 

bed, cries out, and agitates the lower extremities at each evacuation of 
the bowels. 

In the early period of cerebral inflammation there is generally excessive 
restlessness, but as the case goes on, and passes into the stage of coma, the 
child becomes still and quiet, assuming very often the decubitus called by 
the French " en chien de fusil," that is to say, on the side, with the inferior 
extremities strongly flexed, and the arms drawn close to, or crossed over 
the thorax. This position is especially characteristic of the latter stages of 
tubercular meningitis. 

Extreme restlessness, constant tossing upon the bed, or incessant 
changing from the arms to the bed, or from bed to bed, is a very bad sign. 
I have observed it in several different affections; especially in obstinate 
pneumonia, in long-continued intestinal disorders, and in the secondary 
inflammations of measles and scarlet fever. 

Amongst the gestures most deserving of attention are the sudden 
starts, attended with cries, which indicate the occurrence of some painful 
sensation, as that of colic, of stitch in the side in pneumonia and pleurisy, 
and sometimes of shooting pain in the head. The frequent carrying of 
the hand to the head, or to the ear, ought not to pass unnoticed, as this 
is often indicative of headache, or earache. So also of the constant 
application of the hand to the mouth, or the introduction of the fingers 
into that cavity, which often occurs when the child is suffering the odon- 
talgic pain of dentition. Nor should the physician ever neglect to ob- 
serve any peculiar and especially any automatic movements of the limbs, 
and particularly of the fingers or toes. The approach of a convulsive 
seizure is often heralded by warning nature by certain peculiar muscular 
movements. The thumbs are drawn into the palms of the hand, and the 
fingers clasped over them ; or the toes are strongly bent towards the sole 
of the foot, or rigidly extended : sometimes the fingers are for an instant 
convulsively extended upon the hand and drawn widely apart from each 
other; or lastly the muscular movements, instead of being easy, steady, 
and natural, are badly co-ordinated ; they are irregular, uncertain and 
tremulous. This latter character, tremulousness and uncertainty, I have 
often noticed. 

The occurrence of paralysis will often be unperceived for some length 
of time by an inattentive observer. It is to be discovered by the failure 
of the child to move one limb, whilst the others are more or less agi- 
tated, or by taking hold of the limb, and comparing the total want of 
resistance in it, with a certain stiffness and opposition to movement almost 
invariably present in the healthful condition. 

The state of the cutaneous surface is always important, and ought to be 
carefully and systematically examined. The points most requiring to be 



32 INTRODUCTORY ESSAY. 



noted are its temperature, dryness or moisture, coloration, and the pre 
sence of eruptions or swellings. By the temperature, and dryness or 
moisture, taken in connexion with the rate of circulation, we must judge 
as to the existence of fever. The inferences to be drawn from the condi- 
tion of the surface in these respects are the same in children as in adults, 
and they need therefore no particular consideration in this place. 

The coloration of the skin, on the contrary, owing to its greater suscepti- 
bility to change in certain affections, becomes, in the diseases of early life, 
of very considerable importance in diagnosis, and deserves therefore some 
special remarks. 

The physician should be aware, in the first place, that the color of a 
new-born infant is some shade of red, varying from a deep brick-red tint, 
to one of a much lighter hue. The red appearance fades away usually in 
about four or five days, and leaves the surface of a yellowish-white, or in 
some instances of a decidedly yellow color. The yellow color is some- 
times so marked as to impose very readily upon an inexperienced 
person the idea that it must depend on an affection of the liver, or in 
other words, that it constitutes a true jaundice! In a very large majority 
of cases, however, the conjunctiva retains its natural white tint, the 
digestive function goes on with perfect regularity, there is no fever, and 
indeed no marks of decided disorder of the health, sq that the icterode 
hue cannot depend, under these circumstances, on any serious lesion of the 
liver or its appendages, and it is manifestly wrong to regard the case 
as one of disease, or as requiring any treatment. 

Besides the yellow color just described, the cutaneous surface in chil- 
dren, and particularly in those under three or four years of age, very often 
exhibits different shades of a bluish color, which need some attention. 
When the whole skin assumes a decidedly blue tint, the case is one of 
cyanosis or morbus coeruleus, depending on some malformation or disease of 
the heart, or upon imperfect expansion of the lungs. In severe cases of 
this kind, the blue color deepens into a purple, or even blackish hue. If 
this appearance last more than a very few days, there can be little doubt 
that it depends on some malformation or disease of the heart. 

It is quite common to observe in new-born and very young infants a 
bluish tint of the hands and feet, and of the parts around the mouth, 
whilst the rest of the body is pale. These appearances depend commonly 
on some obstruction to the pulmonary circulation, as atelectasis pulmo- 
num, bronchitis, or pneumonia, and increase, diminish, or disappear, 
according to the course of the causative malady. In older children, the 
blue color of the skin rarely reaches any considerable intensity, unless the 
condition has existed from birth, or soon after; but it is not at all uncom- 
mon to meet with faint, but perfectly perceptible shades of that color, 



re- 



SIGNS FROM THE CUTANEOUS SURFACE. 33 

depending on the asphyxiated state which occurs in croup, capillary bron- 
chitis, pneumonia, and sometimes in laryngismus stridulus. It is hardly 
necessary to add that a very slight blueness of the fingers and toes is 
sometimes observed in the cold stage of intermittents. 

There is one other alteration in the color of the skin which is deserving 
of notice in a practical point of view. It is an excessive pallor, occurring 
sometimes in diseases which obstruct the respiratory function. I have 
been most struck with it in the capillary bronchitis, or suffocative catarrh, 
of young children, and in membranous croup. The whole surface assumes 
a dead white hue, which seems to depend on a total want of blood in the 
cutaneous capillaries. The nose is white, the ears become white and 
diaphanous, and the only relief the eye meets with in gazing upon what 
seems an almost alabaster countenance is the still pink or bluish lips, the 
dark eyebrows and eyes, and perhaps a somewhat leaden tint of the cir- 
cumference of the mouth and of the forehead. In strongly marked cases 
the whole surface exhibits this white or blanched appearance, even the 
fingers and toes. When this condition has lasted for several hours, or a 
day or two, the hands and feet sometimes assume a bluish look, which 
may last until death occurs, or until the attack approaches a favorable 
termination. This condition of the surface, when occurring in cases 
attended with obstruction of the respiratory function, has always appeared 
to me an indication of imminent danger to the patient ; and, indeed, when 
it lasts more than one or two days, it has very generally proved the 
harbinger of death. 

The clinical examination of the cutaneous surface cannot be considered 
complete until it has been made with reference to the presence of eruptions, 
of swellings from cedema, of inflammation, tumors, and lastly, as to that of 
diseases of the joints. The inquiry in regard to the presence of eruptions 
is a very important one, from the fact that children are particularly liable 
to attacks of the exanthematous and other eruptive affections. Many 
attacks of sickness, beginning with violent fever and other serious symp- 
toms, which would otherwise remain entirely obscure, or unexplained, until 
a much later period from the onset, may be accounted for at an early period 
by a minute examination of the skin. So, in the latter stages of long and 
debilitating maladies, in the disorders which follow scarlatina, and in cardiac 
and hepatic diseases, a proper inspection of the surface will reveal cedema- 
tous effusions that might, if this search were neglected or carelessly 
prosecuted, remain undiscovered. The same remarks will apply to in- 
flammations of the articular cavities, and to the swelling of those parts 
produced by rheumatism. In fact, in infants and in children under six or 
even eight years of age, the physician must depend, in great measure, for 
information as to the nature of the case, on his own unassisted explorations, 

3 



34 INTRODUCTORY ESSAY. 

and knowing this he should leave nothing neglected or forgotten that 
may increase his knowledge of the state of health of the individual 
before him. He should cultivate a habit of minute, systematic, and 
patient investigation, since, by forming to himself such a method in his 
daily walks, he will assuredly attain in the end a tact and sagacity that 
will not often be at fault. 

The Pulse. — The pulse of the child, in order to be judged of to any 
real advantage, must be examined during the state of quiet, and, if pos- 
sible, it should be felt whilst the child is either asleep or dozing. During 
the waking state, a young infant is in such constant motion, that it is very 
difficult to perceive the pulsations of the radial artery, and impossible to 
judge of their force or volume, in consequence of the rising and falling of 
the flexor tendons of the forearm, and because, also, of the natural softness 
and smallness of the pulse at that age. In older children, the moral dis- 
turbance occasioned by the visit of the physician in most instances, and 
the irritability and nervousness accompanying the sickness, will either 
cause the patient to resist the attempt to touch the arm, or else produce 
so great an effect upon the rate and force of the circulation, as to render 
very uncertain and unsatisfactory any conclusions to be drawn from the 
examination. If possible, therefore, the circulation should be examined 
during sleep. If this be impracticable, the' child ought, when still nursing, 
to be put to the breast, or when weaned, it ought to be quieted by soothing 
treatment, by toys, or by the promise of a toy. 

It is essential that we should know what is the average of the healthy 
pulsations of the child, in order to obtain a standard of comparision by 
which to judge of any departure from that average in disease. Observers 
have varied not a little in the results at which they have arrived from 
their examinations upon this point. By selecting those, however, which 
appear to have been made with the greatest care, and under the most 
favorable circumstances, we shall doubtless obtain an average entirely 
worthy of confidence. It will be necessary, also, to obtain averages for 
different periods of childhood, since the rate of the circulation varies to a 
very great extent at different ages. I shall therefore give the rate of the 
circulation for new-born children (one to ten days old) ; for the period 
from four months to six years ; for that from six to nine years ; and for 
those from nine to twelve, and from twelve to fifteen years of age. 

The average rate of the circulation in very young infants is from one 
hundred and one to one hundred and two in the minute, the former being 
the result obtained by M. Billard in children from one to ten days old, as 
nearly as it can be gained from his statements, and the latter, the one 
obtained by M. Roger, in infants from one to seven days old (De la Tempe- 
rature chez les Enfants, Paris, 1844). The physician ought, however, to be 



! 



PULSE. 35 

aware of the fact that, though the above is the average rate of the circulation 
at the age mentioned, the pulse may range very much above or below that 
average, without necessarily indicating a morbid state of the health. Thus, 
though the average frequency in forty children from one to ten days old, 
observed by M. Billard, was one hundred and one, it was less than eighty 
in eighteen, whilst in fourteen it was between one hundred and one hundred 
and twenty-five, and in six between one hundred and thirty and one hun- 
dred and eighty. All these children, he assures us, presented every mark 
of good health. 

The average frequency of the pulse during the first year may be stated 
at about one hundred and fifteen, at least such is the result obtained by 
me from an examination of seven observations given by M. Roger, made 
on children of from four to nine months old. This result, it will be ob- 
served, shows that the pulse is not so frequent during the first few days 
after birth, as it becomes at a somewhat later period, which, moreover, 
agrees with a previous statement to the same effect made by M. Valleix. 
This latter author is of opinion that at seven months of age the pulse is 
much more frequent than some days after birth, and that it afterwards 
falls gradually as the child advances in years. 

I am not acquainted with any observations upon the rate of the circula- 
tion during the second year of life, except those of M. Trousseau, who, 
according to M. Bouchut (3f an ucl Prat, des Mai. des Nouv.-Nes, p. 133, 
Paris, 1845), gives as the average between one year and twenty-one 
months, one hundred and eighteen. 

M. Becquerel (Traite Theoriquc et Prat, des Mai. des Enfants, Paris, 
1842), gives us the result of his observations upon thirty children, between 
two and six years of age, during sleep and in the waking state. In the 
former state the average was seventy-six; in the latter, ninety-two. 

Between six and nine years of age, the same observer found the average 
during sleep to be from seventy-three to seventy-four, whilst in the waking 
state it was ninety. Between nine and twelve years, the average was, 
during sleep, seventy-two, in the waking state, eighty. Between twelve 
and fifteen years the rate was seventy whilst the children were asleep, and 
seventy-two when awake. Roger gives seventy-seven as the average be- 
tween six and fourteen years. 

One very striking fact attracts our attention in the above statements : 
the much greater difference between the rate of the circulation during 
sleep and during the waking state, in very young children, and in those 
who are somewhat older. Thus, whilst there is a difference of seventeen 
pulsations in the minute, in the rate of the circulation during sleep and in 
those who are awake, between the ages of two and six years, the differences 
under the two conditions mentioned, amounts to only two pulsations in the 



36 INTRODUCTORY ESSAY. 

minute in children that have reached the age of between twelve and fifteen 
years. 

The circulation is somewhat more rapid in girls than boys. This dif- 
ference should be borne in mind, but as it amounts to only about five beats 
in the minute, it is insufficient to be of any very decided value in diagnosis 
or prognosis. 

After these specifications as to the rate of the circulation in children, I 
shall pass on to some general remarks upon the method of examination of 
the pulse, and upon some other of its important characters. 

M. Bouchut (Loc. Cit., p. 129), remarks that in infants at the breast 
" the palpation of the pulse is almost impossible. It may be counted, 
but its force, feebleness, size, and hardness, can scarcely be appreciated; 
the intermittent character is the only phenomenon upon which no doubt 
need rest; it is moreover, the only one of any value." These opinions of 
M. Bouchut, though true in some degree, seem to me to be much too 
strongly stated, since I am quite sure that it is very easy to detect great 
differences in the force, size, and tension of the pulse of the same child in 
health and in disease, and of different children laboring under different 
diseased conditions. These differences can be detected by careful observa- 
tion from a very early age, and after two months may be readily recog- 
nised, when the variation from the state of health is at all considerable. 

The intermittence of the pulse above alluded to, should rather be ex- 
pressed by the word irregularity, since the pulse is not properly intermit- 
tent, but merely irregular in its rhythm. This is quite a common feature 
in the pulse of children, and, be it noted, is much more frequently met 
with during sleep than in the waking state. M. Becquerel met with 
irregularity of the pulse in twenty-four of one hundred and fifty children 
examined during wakefulness, and in fifty-five of one hundred and fifty 
during sleep. It is clear, therefore, that mere irregularity of the circula- 
tion, independently of other symptoms, is not a sign of disease, since it was 
present in one-sixth of those awake, and in a little more than a third of 
those asleep. It should be observed, too, that the greatest irregularity 
exists when the pulse is slowest (in sleep). The chief practical bearing of 
this fact is that we should be careful not to lay too much stress upon slow- 
ness and irregularity of the pulse, as signs of tubercular disease of the 
cerebral meninges, unless they are observed during the waking state, and 
in connexion with other symptoms, particularly with vomiting, constipa- 
tion, and severe headache. 

Another very important characteristic of the circulation of the child, is 
its extreme irritability, which causes its rate to vary to an extraordinary 
degree, even in perfect health. This is the more marked in proportion as 
the child is younger. The slightest disturbance, whether moral or physical, 



EXAMINATION OF THE HEART. 37 

will cause the pulse to rise in a young child, from one hundred or one 
hundred and fifteen, to one hundred and twenty, one hundred and thirty, 
or even one hundred and fifty. From this circumstance may be drawn 
the inference also, that the pulse should always be examined, as before 
stated, during sleep, or during profound quiet. 

There is still another reason which makes it necessary to touch the 
pulse during sleep or profound quiet. This is that when the child is agi- 
tated, it becomes literally impossible, in consequence of the contractions 
of the flexor tendons of the arm, and of the movements of pronation and 
supination, to find, much less to judge, the various qualities, of the 
arterial action. 

Examination of the Heart. — The examination of the heart by aus- 
cultation and percussion ought, and to be of essential aid in diagnosis, must 
be performed whilst the child is still and quiet. It is best made during 
sleep, especially in infants; when this is impossible, it can be performed 
with great advantage during the state of quiet that follows nursing, or 
during that which may often be procured by soothing management, or by 
taking advantage of the fondness that infants show for a strong light, the 
view of which will often suffice to occupy and keep them still. 

The sounds of the heart present the same general characters i^ the 
child as in the adult. They are, of course, more feeble and more rapid, 
conditions which make it difficult, in the young infant, to perceive and 
appreciate any minute change from the healthful sounds. After the age 
of one and two years, however, when the circulation has become slower 
and more steady, the signs yielded by the physical examination of the heart 
become much more valuable and positive, so much so, indeed, as to yield 
results almost as important as in the adult. The first sound is almost 
always duller than the second. They succeed each other commonly with 
perfect regularity, and have the same interval between each, in the same 
child. The cardiac sounds are readily heard by placing the ear over the 
precordial region. The extent of surface over which they may be heard, 
will depend on several conditions, particularly the state of quiet or agita- 
tion of the child, the presence or absence of fever, the state of the lung 
as to its consistence (constituting it a better or a worse conducting 
medium of sounds), and the condition of the heart itself as to health or 
disease. 

In a healthy child, who is undisturbed by any cause of irritation, and 
particularly in one sleeping, the sounds are distinctly audible over the 
whole precordial region, and under the left clavicle. In many subjects 
they can be heard over the whole front of the thorax, but become, of 
course, feebler, in proportion as we recede from the precordial region. 
Usually they are heard quite as distinctly under the right clavicle as over 



38 INTRODUCTORY ESSAY. 

the right nipple of that side, in consequence, no doubt, of their trans- 
mission in an upward direction by the aorta. They are never heard over 
the posterior walls of the chest in children in perfect health, and whose 
circulation is entirely undisturbed. In those who are awake and agitated, 
and in those who have been making severe muscular exertions, the cardiac 
sounds are very loudly audible over the whole front of the thorax, and 
even through to the back of the chest. 

When the lungs are indurated by inflammation, as in pneumonia, 
they transmit with great distinctness, from having become better con- 
ducting media, the cardiac sounds to the back. This circumstance some- 
times becomes a valuable aid in the diagnosis of pneumonia. I have been 
enabled to satisfy myself of the existence of pneumonia in the lower lobe 
of the right lung, in a doubtful case, from the fact that the sounds of the 
heart were much more clear and distinct over the right inferior, than over 
the left inferior dorsal region. 

The precordial region is decidedly less sonorous on percussion than the 
parts of the thorax directly over the lungs. This diminution of sound is 
distinct enough to be evident to any ordinary ear, but it rarely amounts to 
absolute flatness. The region exhibiting this dulness of sound is the same 
in position as in the older person. It occupies the space corresponding to 
the cartilages of the fifth, sixth, and seventh ribs, and is situated, there- 
fore, between the left nipple and the left edge of the sternum. Its mea- 
surements, as given by MM. Rilliet and Barthez, are one and a half to 
three inches in a transverse, by one and a half to two and a half in a 
vertical direction. The region of dulness is described by those observers as 
being represented by a circle or ellipse, the transverse diameter of which 
extends from the nipple to the sternum, or more rarely towards the xiphoid 
cartilage. In children over six years old the nipple sometimes lies above 
the middle line of this space. 

Respiration ; its Rate and General Characters. — The respira- 
tion, like the pulse, to be examined with any advantage to the explorer, 
must be investigated whilst the child is still and quiet. In the young 
infant it should be done during sleep, as it is only then that we can find 
the breathing uninfluenced by disturbing causes other than those con- 
nected with deranged health. In the older child, the play of whose func- 
tions is more steady and regular, and less readily jarred by trivial causes, 
this part of the clinical exploration may be made during the waking state ', 
but, still, it must be done whilst the patient is quiet and tranquil, else 
the results obtained will necessarily be less certain and reliable than under 
the opposite state of things. 

The respiration ought always to be counted by the watch, if possible, 
especially by the young practitioner. This is the only mode in which a 



RESPIRATION, ITS RATE, ETC. 39 

perfectly accurate idea of the frequency of the respiration is to be ob- 
tained. It sometimes happens that a greatly increased rate of the 
breathing will pass unnoticed by the physician, from the fact that it 
continues to be regular, and without effort. I have known children 
to breathe eighty times in the minute without presenting any appearance 
of labor or effort in the act, without cough, and without the least 
wheezing or sound to be heard at a short distance from the patient. 
Under these circumstances the great rapidity of the respiration might 
very well pass unnoticed, especially by inexperienced practitioners; and, 
be it remarked, this would be particularly apt to happen, were the atten- 
tion of the physician addressed to some other part of the economy than 
the thorax, as the seat of the sickness. For instance, in latent pneumonia, 
when this simulates meningitis, or when it is conjoined with gastro- 
intestinal symptoms, the failure to note a greatly increased rate of the 
breathing might very well occur. In many cases of secondary pneumonia 
it might also take place. In children, who have been long sick with 
diseases that debilitate and impoverish the health, a sudden aggravation 
of the symptoms dependent on collapse of the lung might be misunder- 
stood and falsely explained, for the want of this precaution. It is there- 
fore a good and useful rule for the young practitioner always to count the 
respiration, when he has to do with a case presenting the least obscurity 
of diagnosis, since this simple habit may guide him to the real seat of 
disease, which else he might often mistake. 

The rate of the respiration in children is very different at different ages, 
a circumstance that should always be recollected in the examination of 
the diseases of early life. The average frequency of the breathing in new- 
born children and during the first week of life, is thirty-nine, according to 
M. Roger. It may rise, however, upon very slight disturbances, to fifty, 
sixty, or even eighty, while it is not at all unusual to find it at twenty- 
five or thirty in perfectly healthy infants during sleep. Between the ages 
of two months and two years the average is about thirty-five. Between 
two and six years, the average is eighteen during sleep and twenty-three 
during the waking state; from six to twelve years, the average during sleep 
is eighteen, and in the waking state twenty-three ; from twelve to fifteen 
years, it is eighteen in the former, and in the latter twenty. It will be ob- 
served, therefore, that after the age of two years, the rate of the respiration 
is nearly the same throughout the remainder of the period of childhood; it 
changes so little, indeed, that the same average will answer perfectly well 
for all practical purposes throughout that period. 

The other characters of the respiration require some attention on the 
part of the practitioner. In the first place, the diaphragm plays a more 
important part in the process in the child than in the adult. In the young 



40 INTRODUCTORY ESSAY. 

infant, indeed, the function is carried on almost wholly by the action of 
that muscle, so that the respiration is correctly described by the technical 
term of abdominal. The walls of the chest are almost motionless. On 
this account the rate and characters of the breathing can be best studied 
in young children, by examining the abdomen, the movements of which 
being strong and marked, are much more easily seized by the eye than are 
those of the thorax. 

During perfect quiescence, and especially during sleep, the breathing of 
a young child is soft, regular, though less so than in the adult, and per- 
fectly noiseless ; it is necessary to place the ear close to the face or chest 
of the child, and to listen attentively, in order to hear the breathing. In 
the young child, and especially the young infant, the breathing is, in the 
waking state, very different from that of the adult. It is short, irregular, 
uneven, and marked by occasional pauses, followed by a hurry and pre- 
cipitation of the movements. These peculiarities in the breathing of the 
infant, appear to depend on the weakness and imperfect action of the 
muscular apparatus at that early age, which causes the various movements 
of the body to be hesitating and uncertain, and without that steadiness 
and evenness which are characteristic of matured strength. After the age 
of two years, these irregular and tumultuous movements cease, and the 
breathing becomes more regular and even, like that of adults. 

In the inflammatory affections of the lungs, pneumonia, bronchitis, and 
pleurisy, the respiration is almost invariably accelerated. In extensive 
pneumonia, and in capillary bronchitis, it becomes very rapid, rising to 
eighty or one hundred in the minute. In pleurisy and simple ordinary 
bronchitis, it seldom becomes so frequent, not exceeding, usually, forty or 
fifty. In severe pneumonia the rhythm of the movement sometimes be- 
comes inverted : the pause occurs at the termination of the inspiration in- 
stead of the expiration. The patient makes first a violent and labored 
expiration, bringing into a kind of convulsive action all the expiratory 
muscles of respiration ; instantly after the expiration follows a rapid and 
full inspiration ; then occurs a momentary pause, and again the respiratory 
act begins with the labored expiratory effort. This kind of respiration 
is a very unfavorable symptom, as it is indicative of a most dangerous 
oppression. It is particularly apt to occur in infants, and very young 
children. It has been called expiratory respiration. 

The respiration, though almost invariably accelerated in pulmonary in- 
flammations, sometimes retains its normal rate, or even falls below that 
rate. This occurs, I believe, only under one condition of things ; when 
the forces of the constitution have been sapped by previous disease, or ex- 
hausted by the long continuance of the thoracic inflammation. It is there- 



SIGNS FROM THE RESPIRATION. 41 

fore met with in cases of secondary inflammations, and in those of the 
chronic form. 

The respiration is very much increased in frequency as a general rule in 
the form of disease recently described under the title of Atelectasis Pul- 
monum, or collapse of the lungs. When, therefore, a young child who has 
been exposed to the causes of this disease (feebleness at birth, exhausting 
disease, or debilitating hygienic conditions), is suddenly seized with hur- 
ried respiration, slight cough, paleness or blueness, with coldness of the 
cutaneous surface, and in whom there are but few and unimportant 
physical signs of pulmonary disease, there is very good reason for sup- 
posing that some portion or portions of the lungs have become collapsed, 
or in other words, have ceased to admit air. 

The respiration often lends some assistance in the diagnosis of cerebral 
affections. In acute meningitis, accompanied by violent febrile reaction, 
it is more frequent than natural, but often irregular. When the early 
stage passes into the stage of coma, the breathing becomes slow and ir- 
regular. In tubercular meningitis it is seldom increased in frequency 
except for a day or two before death, whilst in the middle period of the 
disorder, it is either continued at its normal rate, or becomes slower. 
During that period, also, it is almost always extremely irregular, and 
is interrupted by long and mournful sighs, which, to the ear of the 
experienced physician, who hears in them the almost certain prognostic of 
approaching death, have an inexpressibly touching sound, increased ten- 
fold by the consciousness of his utter inability to control the fatal tendency 
of the malady. 

There is a peculiarity of the respiration noticed by Dr. George A. Rees, 
as occurring in collapse of the lung or atelectasis, and which I have 
myself seen, that ought not to be passed by unnoticed. It is that, during 
the inspiratory effort, the ribs move inwards or backwards, towards the 
mesial line of the trunk, instead of outwards, as in ordinary respiration, 
thus diminishing in place of increasing the transverse diameter of the 
thoracic cavity. The explanation of this peculiarity is the following : 
" When the diaphragm descends, unless the lung expand at the same time, 
a vacuum would result if the thoracic walls remained immovable, or en- 
larged as in healthy respiration ; but the parietes being flexible, especially 
at this early period of life, yield to the external atmospheric pressure, pass 
inwards instead of outwards, and the capacity of the cavity continues in 
relation with the imperfectly expanded lung." 

Auscultation and Percussion of the Lungs. — This portion of 
the examination of the sick child ought to be performed, if possible, whilst 
the patient is still and quiet. Unfortunately, however, it happens in a 
large majority of cases that the disturbance of position necessary to effect 



42 INTRODUCTORY ESSAY. 



lrri- 
ause 



the exploration, and the presence of the physician, together with the 
tability of nerves and temper occasioned by sickness, almost always cause 
more or less resistance on the part of the child, and produce violent 
screaming and struggling. In young infants we have to contend only 
against the instinctive resistance to any physical disturbance naturally 
attendant upon sickness and suffering. In older children, who have 
learned to distinguish between familiar and strange faces, and in whom 
the will has begun to act, there is added to the instinctive resistance of 
the infant an opposition of the most strenuous and annoying kind, founded 
upon the natural fear of a stranger, and upon a mental determination not 
to be interfered with or incommoded by the movements and changes of 
position necessary for a careful examination. 

For these reasons, the physical exploration of the chest in young sub- 
jects is often to be accomplished only with great difficulty, and in the 
midst of the most violent screaming, struggling, and contention. It is 
important, therefore, to avoid these obstacles if possible. This can only 
be done by the employment, on the part of the attendants and physician, 
of the most soothing, gentle, and patient management ; and in this way, 
let it be remarked, it can be done in a large majority of cases. The pos- 
session by the physician of a quiet and yet decided manner, the power to 
interest and attract a child by entering with active sympathy into its little 
amusements and pursuits, the skill to engage its attention by the exhibi- 
tion of some book or toy, or the mere influence he may exert to calm its 
terror or excited irritability, by a soothing voice and gentle persuasion, 
will, in nearly all instances, overcome any resistance offered to the exami- 
nation by children over two years of age. Nevertheless, in very young 
children, and in not a few that are older, no gentle means whatever will 
overcome opposition. Here the exploration must be made in the midst of 
struggles and cries, and though the results obtained will be less clear and 
positive than when the child is reasonable and obedient, a great deal of 
most valuable information can be acquired by a quick and dexterous prac- 
titioner. The percussion can be made in the short intervals between the 
cries, or even during their continuance, and by placing the ear close to 
the finger by which it is performed, the sounds elicited can be very well 
heard and judged. The auscultation is more uncertain ; but, by watching 
intently the long and deep inspirations which immediately precede the 
violent cries, the presence or absence of rales, and their characters, the 
freedom with which the air enters the lung, and the existence or non- 
existence of bronchial respiration, can, after some experience, be ascer- 
tained and commented upon, so as to give considerable certainty to the 
diagnosis. 

The particular position in which to place the child, during the examina- 



EXAMINATION OF THE LUNGS. 43 

tion, is of some importance. After the age of three and four years the 
position may be the same as that selected for the adult, if only the patient 
be reasonable and tractable. When, on the contrary, the child resists, it 
should be taken on the lap of the mother or nurse, or else held in the 
arms, with the head inclined over one shoulder, while its back is presented 
to the practitioner. Infants within the year may sometimes be examined 
whilst engaged in the act of sucking ; but this is inconvenient, both from 
the constrained position, and from the circumstance that the inspirations 
are short and imperfect during that act. The French authors recommend 
that the very young infant should be laid, with its face downwards, across 
the hand of the practitioner, who is then to approach the back of the chest 
to his ear. I have found either one of the three following positions most 
convenient, as the case may be : the infant laid across the lap of the 
mother, with its face downwards, and the head hanging a little over one 
knee ; held in the arms, with the front of its body placed against the 
mother's chest, and the head lying over her shoulder; or, lastly, a 
favorite position of mine, placed in a sitting posture upon the lap, sup- 
ported by one hand in front, and by the other holding the occipital portion 
of the head. 

Auscultation should always be performed before percussion, because the 
latter generally alarms or annoys the child, and occasions crying, which 
of course would interfere more or less with the auscultation, were this 
performed after percussion. The auscultation should be made with the 
ear rather than the stethescope ; for the reason that the instrument terri- 
fies the child, and also because it cannot, when the child resists and 
struggles, be kept in contact with the chest. Moreover, the instrument 
is unnecessary except for the examination of the upper portions of the 
thorax in front, and it had better, therefore, be dispensed with. 

Percussion is best made in children by using a finger of the left hand 
as the pleximeter, and by striking with one finger of the right. One 
finger is quite sufficient to elicit all necessary sound in young subjects. 
The strokes should be light and distinct, consisting of short, quick, and 
gentle taps. 

To perform auscultation and percussion with success, the surface ought 
to be quite uncovered. The habit of examining the thorax through one, 
or several thicknesses of clothing, which some persons fall into, is a most 
careless one, and cannot but lead to uncertain and erroneous results. 

As a general rule, it is sufficient, in young children, to examine the 
posterior portion of the thorax. Doubtless, it is more accurate and 
artistical to explore the whole chest, and this ought to be done in all 
obscure cases. But when the child is sick and suffering, when it is irri- 
tated and exasperated by the presence of a stranger, or by coercion, and 



44 INTRODUCTORY ESSAY. 

still more, when it is weak and exhausted by long or violent illness, it 
becomes of the greatest importance to shorten, as much as possible, the 
time occupied in the examination. For these reasons, it is well to be 
aware of the fact that, in nearly all inflammatory diseases of the lungs, 
the morbid changes affect first and most severely the posterior surfaces of 
those' organs. This is thought to depend on the fact that the child passes 
so large a portion of its time in the recumbent position as to cause the 
fluids of the body to gravitate towards the dependent parts of the lungs, 
and thus to determine the beginnings of inflammatory action in that direc- 
tion. Certain it is, be the explanation what it may, that it is rare to find the 
anterior surface of the lungs affected either with bronchitis, pneumonia, 
or pleurisy, whilst the posterior surface is healthy. When, therefore, 
upon auscultation and percussion, no signs of disease are met with over 
the dorsum of the thorax, we may feel pretty well satisfied that the lungs 
are healthy. Nevertheless, in all doubtful cases, the examination ought 
to be extended to the whole chest,'in order to make what was, before this has 
been done, only a strong probability, a certainty. Whenever, also, it is 
important to ascertain the precise amount of disease in any serious or long- 
continued sickness, the front as well as the back part of the chest must be 
examined. 

The respiratory sounds are not of the same character precisely in the 
child as in the adult, and of this the physician ought to be aware. In 
children the vesicular murmur is stronger than in the adult, so that it 
assumes somewhat of a blowing or bronchial sound. It was in conse- 
quence of this peculiarity that Laennec gave it the name of puerile respi- 
ration, which, though a mark of health in early life, is, at the period of 
maturity, an indication of a morbid change in some portion of the 
pulmonary parenchyma. It ought to be remarked, however, that in 
infants under two, and particularly in those under one year, the vesicular 
murmur is, in ordinary respiration, weaker than in adults; owing, no 
doubt, to the fact that the inspirations are short and imperfect, not dis- 
tending the lungs to their full capacity. When, however, from any 
cause, a sigh, a sudden disturbance, or the act of crying, a full and com- 
plete inspiration takes place, so as to dilate thoroughly the pulmonary 
structure, the murmur becomes at once loud and strong, or, in other 
words, puerile, as in older children. 

The inspiration and expiration bear the same relation to each other as 
in the adult; the expiration being much shorter and feebler than the 
inspiration, though, at the same time, it, like the inspiration, is louder 
than in the adult. In some instances, however, and especially over the 
posterior inferior, and lateral regions of the thorax, no sound whatever 
is heard during the accomplishment of the expiration. This absence of 






EXAMINATION OF THE LUNGS. 45 

sound during expiration is the more apt to be met with in proportion as 
the child is younger. 

When a young child is made to breathe forcibly and rapidly, the 
respiratory sounds assume certain characters, even in perfect health, which 
might mislead an inexperienced observer. The inspiration is short, loud, 
and hard, so as to assume somewhat of a blowing character, resembling 
not a little the sound of bronchial respiration. At the same time, the 
expiration becomes louder also, and longer, which two circumstances, rude 
or even blowing inspiration, with loud and somewhat prolonged expira- 
tion, may very well deceive a young or careless practitioner. 

The respiration is most clear and characteristic over the anterior, lateral, 
and posterior inferior regions of the thorax. Over the origin of the 
larger bronchia, that is to say, in the interscapular region, the respiration 
is very strong, so as to resemble very closely bronchial blowing. Here, 
also, the expiration is often very marked; it is sometimes heard as long, or 
even longer than the inspiration. Over the scapulas the sound of respira- 
tion is always feebler than elsewhere, except in the prsecordial region, 
from the interposition of the scapulas and of thick muscles between the 
ear and the lung. 

Percussion yields a much louder and more sonorous sound in children 
over two years of age than in adults, — a circumstance always occurring 
co-incidentally with the presence of puerile respiration, and dependent on 
the fact that the function of respiration is, at that age, very active, and 
the lungs therefore filled to their utmost capacity with air. In infants 
under two years of age, the sonorousness varies to a considerable extent in 
the same child. "When the respiration is, as it usually is, gentle and 
easy, the inspirations being rather feeble and incomplete, the amount of 
air contained in the lungs will be somewhat deficient in comparison with 
what their cells might contain, and the sound yielded upon percussion 
will necessarily be rather dull and insonorous. When, on the contrary, 
the respiratory process is quick, active, and energetic, from any cause, 
so as to give rise to the auscultatory phenomenon called puerile respira- 
tion, the percussion will be loudly sonorous, as it is in the later periods of 
childhood, owing to the thorough dilatation of all the air cells, and the 
consequent presence in the thoracic cavity of a large amount of inspired 
air. 

The sonorousness of the thorax is different in different parts in children, 
as in adults. In front, the percussion is most sonorous from just beneath 
the clavicle on the right side down to one or two inches below the nipple, 
where it gradually becomes dull, owing to the position of the liver. On the 
left side the sonorousness is modified by the presence of the heart in the 
manner already mentioned. Below the praecordial region we again have 



46 INTRODUCTORY ESSAY. 

pulmonary resonance down to the sixth or seventh ribs, below which is 
heard the tympanitic sound of the stomach. 

Behind the sound is very dull above the spine of the scapula, and con- 
siderably so over the scapula beneath its spine. Over the interscapular 
space it is clear and strong, and more so in the lower than in the upper 
half. Beneath the inferior angle of the scapula, likewise, it is clear and 
full, until we approach the inferior margin of the thorax, where it is 
dulled, even above the lower edge of the lungs, by the presence beneath 
of the liver on one side, and of the spleen on the other. Over the right 
side the dulness begins a little higher than over the left, in consequence 
of the greater bulk of the liver than of the spleen. 

The lateral regions are very resonant in their upper portions, but become 
dull as we approach the liver on the right side, and the spleen on the left. 
On the left side the pulmonary sound is often entirely eclipsed by a tym- 
panitic resonance occasioned by the presence of gas in the stomach. 

In practising percussion in children it is necessary to strike gently, 
because, from the great natural sonorousness of the chest in early life, any 
considerable force would bring out so much sound as to prevent the re- 
cognition of a degree of dulness which might readily be perceived by the 
use of more gentle blows. It is necessary always to compare the two sides 
together as in adults, since this often leads to the detection of a degree of 
obscurity which might be otherwise inappreciable. Yet, and the physician 
ought to be well aware of this, the comparison of the two sides is not quite 
so useful in young as in mature subjects, because of the fact that the 
diseases in which the differential comparison is most important, pneumonia 
and pleurisy, are more frequently double than in adults. It becomes, for 
the same reason, very important to compare the upper and lower portions 
of the thorax behind, since we may assure ourselves of the existence of 
dulness below, of which we were before doubtful, by the fact that the 
sound is less sonorous in that region than above, which is, as already 
stated, the very opposite of the healthy condition. 

Examination of the Abdomen. — It is often very important to ascer- 
tain by palpation, the form, size, and degree of tension of the abdomen, 
the presence or absence of effusions within its cavity, and the condition of 
the organs which it contains ; to learn by percussion the degree of reso- 
nance which it affords ; and lastly, to find by pressure whether it be un- 
naturally tender to the touch or not. By a careful inquiry into these 
various points, and a proper comparison between them and the rational 
symptoms presented by the patient, we shall be able to discover the 
existence of tumors, of hypertrophied organs, of unusual developments of 
gas in the intestines, of dropsical effusions, of enlarged and hardened 



EXAMINATION OP THE ABDOMEN. 47 

mesenteric glands, of gurgling, and of soreness on pressure, caused by in- 
flammation of some of the contents of the cavity. The examination 
should be made, if possible, whilst the child is still and composed. It is 
best, therefore, to perform it before auscultation and percussion, in children 
who are old enough or amiable enough to be willingly quiet, since the 
length of the examination of the thorax often wearies out their patience, 
and they refuse to submit to further inspection; whilst in infants and in 
children who obstinately resist the examination, it matters little at what 
particular period it is attempted, since it must be done at last in the midst 
of cries and general agitation. It is, at all times, a difficult and not very 
useful examination, unless the patient consents to it freely and without 
fear. It is very necessary, therefore, to resort to every means to obtain 
this quiet consent. In children over a year old, this condition is to be 
obtained only during deep sleep, during the act of nursing, or when the 
patient is awake, by so pleasing and attracting its attention by toys, by 
soothing voice and manners, as to cause it to forget what is passing. The 
reasons why the examination is useless unless made during a state of calm, 
are very obvious. In the first place, the contractions of the abdominal 
muscles give to the walls of the abdomen such a degree of hardness and 
rigidity, that it is impossible to learn anything in regard to the state of 
the parts within, except merely what can be learned by percussion ; and 
in the second place, no acuteness of perception will enable us to distin- 
guish between the cries of anger and fright, and those that may proceed 
from pain occasioned by pressure. 

M. Valleix recommends a plan in the case of young infants, by which 
tenderness on pressure may very generally be recognised. It is as follows. 
He carries the child, carefully sustained in the arms, suddenly before a 
bright light, either that which pours in at a large window, during day- 
light, or that of a bright artificial light at night. The infant, whose 
greatest pleasure consists in gazing at a bright light, almost always ceases 
to scream and becomes perfectly quiet while thus attracted. Seizing this 
opportunity, the physician should pass his hand under the clothes, and 
applying it directly over the cutaneous surface, he may first learn by a 
rapid palpation the general characters of the abdomen, and then ascertain 
by sudden and decided pressure whether it be abnormally sensitive. If 
the pressure gives pain the infant will cry out at the moment, while at 
the same time a sudden contraction of the countenance will assist to show 
the perception of some painful sensation. Should the infant, on the con- 
trary, continue to gaze fixedly at the light, without noticing the ma- 
noeuvres of the physician, it is fair to conclude that there is no inflam- 
matory tenderness present. 

Examination of the Mouth and Fauces. — In all obscure attacks of 



48 INTRODUCTORY ESSAY. 

sickness occurring in young children, and even in those who have attained 
to the faculty of speech, the physician ought to be most careful to inspect 
the condition of the mouth and fauces, since not a few cases of fever which 
seem at first view inexplicable, are at once made plain by this simple 
exploration. I was once called to see a child three years of age, who had 
been sick three days with fever, thought by intelligent and educated 
parents to depend on gastric derangement. A single look into the throat 
showed it to be completely clogged up with pseudo-membranous exuda- 
tions, whilst a slight hiss in the inspiration, and a husky voice, declared 
that the same fatal product was just entering the larynx. The time for 
successful action had slipped by ; the patient died two days after in the 
agonies of slow croup. On another occasion I was called to take charge of 
two children in one family who had been ailing several days with feverish 
symptoms, loss of appetite, languor, and some complaint of sore throat. 
In both I found the fauces covered with plastic deposit, and both died a 
few days after of membranous croup. Within two years I attended a 
child between five and six years old, for a period of four days, with 
irregular fever, some vomiting, total anorexia, languor, indisposition to 
play, and rare complaints of pain in the chin and neck, that were not 
mentioned to me by the attendants, I having all the time the idea that the 
attack was one of gastric embarrassment. Greatly to my amazement and 
consternation, the mother informed me on the fifth day that she had seen 
something white in the throat. Upon examination I found both tonsils 
covered with whitish exudation. Happily the disease had not extended 
beyond those glands, and still more fortunately, it was arrested and cured 
in two days by the application of a strong lunar caustic solution, and by 
the administration of some doses of calomel combined with minute quan- 
tities of tartar emetic. 

In croup, also, in whatever form it may make its attack, the fauces 
ought to be closely watched, in order to know by the presence or absence 
of false membrane, the probability or improbability of the case being one 
of the membranous kind. In scarlatina and measles, especially in the 
former, the throat ought to be examined each day, to ascertain its precise 
condition, and particularly to learn whether there be present any disposi- 
tion to membranous, ulcerated, or gangrenous angina. 

In young infants, also, the mouth requires a thorough examination from 
time to time in all their ailments, and especially in their digestive diseases, 
since they are liable to thrush, to aphthae, and in chronic and debilitating 
maladies, to gangrgena oris. In teething children the act of dentition re- 
quires that the mouth should be inspected occasionally in order to ascer- 
tain the state of that process, and to detect the existence of the form of 



EXAMINATION OF MOUTH AND THROAT. 49 

stomatitis called ulcerative, which generally occurs between the ages of 
one and five or six years. 

The mouth can be readily examined by pressing upon the chin with 
force sufficient to cause the child to separate the jaws. In the young 
infant this very generally produces crying, during which the mouth is 
widely opened, and the state of the cheeks, lips, gums, and tongue can be 
perfectly well seen. In an older child, who refuses to open the mouth, or 
to keep it open, the handle of a smooth silver spoon is the best instrument 
to employ by which to effect our purpose. 

The throat cannot be well seen at any age, except by depressing the 
base of the tongue, which is best done by means of a spoon-handle, as 
above directed. When a child refuses obstinately to open the mouth, and 
resists with violent struggles, it should be taken on the lap of a strong 
assistant, with the back of its trunk resting against the chest of the 
assistant, whose arms should maintain, by being crossed over the body and 
limbs of the child, its more vehement movements. Another assistant 
must hold the head of the child steady, whilst the physician obliges it 
to open the mouth, either by closing the nostrils with the fingers, or by 
slowly and gently, but firmly, insinuating the handle of the spoon between 
the teeth. After the spoon has once been passed over the tongue there is 
seldom any difficulty in obtaining a good view of the fauces. 

The introduction of the finger into the mouth is of some use as a diag- 
nostic means in the case of infants. It informs us of the temperature of 
that cavity, of the state of its secretions, and, consequently, of its dryness 
or humidity, and of the disposition and ability of the infant to suck. 
When an infant is in good health, it will almost always seize the finger, 
when this is placed in the mouth, and suck vigorously for some instants. 
It will do the same when it is only ailing with some slight malady, and 
in the early stage of more dangerous diseases. But, in severe and 
threatening illness, the infant either refuses to suck upon the finger at 
all, or does so only for an instant. When the mouth is irritated or in- 
flamed, as in any of the forms of stomatitis, the child will open the mouth 
and cry, and make no attempt whatever at suction. In stupor, and espe- 
cially in coma, but little attention is paid to the finger, the infant being 
generally unconscious of its presence. 

By watching the child when put to the breast, we may acquire nearly 
the same information as that just referred to, except that the child would 
naturally make a greater effort to seize the nipple than the finger, and 
would therefore nurse, even though the act of so doing were painful, under 
circumstances in which it might refuse to grasp the finger af all. The 
refusal to nurse, or the nursing but little at a time, may depend on other 
causes, however, than sore mouth. It often depends on some angi- 

4 



50 INTRODUCTORY ESSAY. 

nose inflammation. When this is the case, it may be suspected from the 
peculiar gulping manner in which the child swallows, and from the fact 
that swallowing often causes fits of coughing. It is caused also by- 
dyspnoea. An infant laboring under severe oppression from pneumonia* 
bronchitis, or any other cause, never sucks well and steadily, but rather 
by fits and starts. The nipple is seized often with avidity, and two or 
three swallows are made in quick succession; then follows a pause to 
regain the breath, and then again the effort of deglutition. In a few cases 
attended with very great dyspnoea, that I have seen, the patients have been 
able to swallow only once or twice without pausing, and even then with 
very great difficulty. 

Manner of Taking Drinks. — The remarks just made as to the 
inferences to be drawn from the manner in which the infant sucks, will 
apply also to the mode in which both infants and older children drink. 
A young child drinks continuously, without stopping to breathe. If, 
however, it have any disorder which accelerates the respiration, it will, 
after drinking a few mouthfuls, cease, jerk its head away from the cup or 
spoon, breathe irregularly and hurriedly, and cough. These symptoms 
ought to call attention to the respiratory organs. So, if a child, whose 
breathing is not oppressed, nevertheless drinks with difficulty, slowly, at 
intervals, and apparently with pain, there is reason to suspect some im- 
pediment in the pharynx, and the fauces ought thereupon to be carefully 
examined. 

We may learn also from the manner of drinking whether the child is 
thirsty or not. When it drinks often and with avidity, and yet has a dry 
mouth, it is evident that there is very great thirst. 

Vomiting and the Discharges by Stool. — The physician should 
never think his examination of a sick child concluded until he has inquired 
as to the occurrence of vomiting, and as to the state of the discharges by 
stool. Not only, indeed, should he inquire as to these symptoms, but he 
ought by all means to inspect personally the appearance of the matters 
ejected. This is especially important in regard to the dejections, since no 
description of a mother or nurse, however intelligent, can impart to the 
physician the precise and accurate idea of the state of those discharges 
which even a very rapid inspection would give him. 

Vomiting is of very frequent occurrence in infancy and childhood. 
Owing to the fact that the stomach is much less curved in its shape than 
it is in the adult, and that the oesophagus enters the organ close to 
its left extremity, vomiting and regurgitation take place with great 
readiness, and these are, therefore, very common symptoms in the dis- 
eases of early life. 

The young practitioner must beware lest he regard all kinds of vomiting 



VOMITING AND DISCHARGES BY STOOL. 51 

in the infant as the result of disease. The nursing child is very apt to 
vomit, even when in the most perfect health, especially if it be suckled at 
an abundant breast. This kind of vomiting, however, may be readily dis- 
tinguished from that which depends on some morbid state of the health, 
by the circumstance of the infant's ejecting nothing but the milk which 
it has swallowed, either just as it was drawn from the mother, or slightly 
curdled, and by the fact that it suffers no inconvenience whatever from 
the act, — neither any violent effort, languor, paleness, nor faintness. And 
yet I have known a young practitioner to prescribe antacids and absorbents 
to correct this kind of vomiting, which is most plainly an act kindly 
intended to rid the infant of any excess of food it may have imbibed. 

In older children also, vomiting not unfrequently occurs as a conse- 
quence of over-distension of the stomach with food. When, therefore, after 
vomiting, a child seems relieved and comfortable, when any unpleasant symp- 
toms that may have existed prior to it moderate or disappear afterwards, 
it is fair to conclude that the act has been beneficial, and wrong to regard 
it as the signal of a necessity for giving medicine, or for regarding the 
child as a patient, except insomuch as to watch lest it be sick as an after- 
consequence of having the digestive power overtasked. 

Frequently repeated vomiting, attended with retching and effort, and 
with paleness and exhaustion, or with fever, always indicates some con- 
siderable derangement of the health. It is impossible to ascertain the 
precise cause of such vomiting, except by a proper consideration and com- 
parison of all the symptoms the child may present. The cause may be 
in the stomach itself, consisting of an inflamed state of the organ, or it 
may be a simple indigestion without any inflammatory condition whatever; 
it may be that the cause lies in the intestine, being some inflammation, 
functional disease, or obstruction of that part ; it may be pneumonia or 
pleurisy j it may be the approach of some of the eruptive fevers ; or last, 
and most serious of all, the cause may be some commencing lesion of the 
brain, which, though as yet determining no proper cerebral symptoms, 
shall perhaps be destined, by its inevitable progress, to end the patient's 
life as surely and certainly as if he were struck with that oppro- 
brium of medicine, consumption. The detection of the particular causa- 
tive condition, in any of these forms of vomiting, can be arrived at only 
by a careful study of the whole constitution of the patient, both through 
the rational symptoms that may be present, and by a thorough inspection 
of the different systems of the body by means of the physical methods of 
diagnosis. 

The rule to examine with his own eyes the napkins or cloths of the 
child, ought never to be forgotten by the practitioner, when there is any 
reason to suppose that the alimentary functions are at all deranged. The 



52 INTRODUCTORY ESSAY. 

number of the stools in the twenty-four hours ought also to he ascertained, ■ 
not loosely and carelessly, but precisely and with certainty. Without a 
close attention to these two precautions, it is impossible for the physician 
to obtain really useful and exact notions in regard to the nature of the 
disorder he is called upon to treat, or to judge of the degree of severity 
of the attack. 

I shall not attempt to consider in this place, either the various unna- 
tural appearances of the matters vomited, or ejected by stool, the amount 
of those substances, or the frequency with which the discharges take place, 
since these various circumstances can be treated of in the manner they 
require only when we come to study separately the diseases of which they 
form a part. 

I shall here conclude my remarks upon the methods to be pursued in 
the clinical exploration of the diseases of children. I have only to add 
the wish that those who shall honor them with their perusal, may find 
them of some real assistance in their subsequent studies of the affections 
of early life. They are intended, of course, chiefly for the student and 
young practitioner ; but I cannot help hoping that they may possibly prove 
useful to some who have spent a longer time in the profession, but who 
have never, perchance, given any particular attention to the best modes of 
investigating the diseases of infants and children. 



CLASS I. 

DISEASES OF THE RESPIRATORY ORGANS. 
CHAPTER I. 

DISEASES OF THE UPPER AIR PASSAGES. 
SECTION I. 

DISEASES OF THE NASAL PASSAGES. 

ARTICLE I. 

C OR YZ A. 

Definition; Synonymes; Forms; Frequency. — Coryza is inflam- 
mation of the mucous membrane lining the nasal passages. It is called 
in common language, cold in the head, or snuffles. Underwood describes 
one variety of it under the title of coryza maligna, or morbid snuffles, 
which, he says, is very different from and a far more serious disorder than 
what is usually called snuffles. Dewees makes no reference to it. Eberle 
describes it under the title of coryza. He doubts whether coryza maligna 
ever occurs in this country, and takes his account chiefly from Underwood 
and Denman. 

I shall describe two forms of the disease, the simple, or mild, and the 
severe; the latter including purulent and pseudo-membranous coryza. 
Simple coryza is very common at all ages ; it occurs frequently as a dis- 
tinct disorder, but still more frequently in connexion with laryngitis, 
bronchitis, pneumonia, measles, scarlet fever, &c. The severe form of 
coryza is that which has been called by Underwood coryza maligna, or 
morbid snuffles. Purulent and pseudo-membranous coryza rarely occur 
as idiopathic affections, but are almost invariably- connected with angina 
or other diseases. I met with one case, however, of the purulent form 
unaccompanied by angina or other disease, in 1841, in a child seven weeks 
old. The case proved fatal. I saw another fatal case of the same form, 
connected with simple angina, in 1846, in a child five weeks old. Besides 
these two cases, I have met with four others of the pseudo-membranous 
variety, accompanied by simple angina, in children between two and six 



54 CORYZA. 

years of age, all of which terminated favorably. The two varieties of 
the disease occur, however, as already stated, much the most frequently 
as secondary affections in the course of other diseases, particularly measles, 
scarlet fever, pseudo-membranous angina, &c. I shall not attempt in the 
present article to treat particularly of the cases which accompany the 
eruptive fevers. 

Causes. — The only clearly evident cause of simple primary coryza, in 
most cases, is chilling of the body. Insufficient dress, — a very common 
error in this country, — too low a temperature of the nursery, and exposure 
to bad weather, may often be discovered to have been the causes of the 
attack. 

The causes of the disease, in the two cases of purulent coryza above 
referred to, were unknown. In one the nurse remarked a slight discharge 
of blood from the nose soon after birth, and the coryza dated from that time. 
In the other, the patient, a feeble child, was attacked when two weeks old 
without any appreciable cause. The four cases of the pseudo-membranous 
form occurred in 1845 and 1846, during an extensive prevalence in this 
city of severe scarlet fever, measles, and pseudo-membranous angina and 
laryngitis, which makes it probable that they depended upon the epidemic 
constitution of the atmosphere. The cases of Ililliet and Barthez coin- 
cided generally with primary or secondary purulent or pseudo-membranous 
angina. From the account given by Underwood of coryza maligna, there 
can be little doubt that it was epidemic when observed by himself and 
Denman. The latter author states that in connexion with the coryza 
there was a general fulness of the throat and neck externally ; that the 
tonsils were tumefied, and of a dark red color, with ash-colored specks, and 
in some cases, with extensive ulcerations ; and that some of the children 
swallowed with difficulty : all of which symptoms clearly point to severe 
concomitant angina. 

Anatomical lesions. — The Schneiderian mucous membrane is found 
reddened uniformly, or in points, rough, thickened, and sometimes 
softened. When pseudo-membrane is present, it exists either in frag- 
ments, or lines the whole extent of the nasal passages, and is mixed with 
mucous or muco-purulent fluid, in greater or less quantity. 

Symptoms. — The symptoms of simple coryza are sneezing, dryness of 
the nose at first, soon followed by discharge, which is very small in quan- 
tity in the beginning, and more abundant afterwards, and more or less 
disturbance of the respiration. It is only in young infants that this form 
of coryza is a disorder of any consequence in itself. In older children it 
never injures the health by its own action ; it is of importance merely as 
the sign that a cold has been taken, and ought to be regarded as a hint 
given by nature of the necessity of guarding the child more carefully in 



SYMPTOMS. 55 

future. But, in infants at the breast, and very young children, it assumes 
much greater importance from the very considerable obstacle it opposes to 
the act of respiration. At this early age, in fact, coryza becomes a serious 
and even dangerous disease. If primary, it causes great distress and dis- 
turbance to the child, interrupting its sleep, interfering with the act of 
nursing, and, in some instances, so impeding the function of respiration, 
as to bring on slight, and more rarely, dangerous asphyctic symptoms. 
It may, undoubtedly, occasion, in weak and debilitated children, more 
or less extensive collapse of the lungs, an accident which will explain 
the imperfect performance of the hematosic function in some cases, 
where the only palpable disease is this apparently insignificant one of 
coryza. 

When simple coryza exists in connexion with bronchitis and pneu- 
monia, it adds to the severity of those disorders. In children over three 
or four years old, and particularly in those who are vigorous, it seldom 
gives any serious trouble. But in young infants, and in weakly children of 
any age, its influence upon the symptoms is often very marked. The effort 
to breathe through the nasal passages, when they are partially or wholly 
occluded by the inflammatory swelling of their lining mucous membrane, 
or by abundant and viscid secretions, fatigues and wears away the strength 
of the child, exhausts its energies, and renders it less able to resist the 
pressure of the sickness. But not only this j — as in primary coryza, the 
entrance of air into the lungs is impeded, and the hematosic function is 
thereby interfered with : at the same time, the existence of an obstacle 
to the full inspiratory movement, in addition to that which exists in the 
lungs themselves from bronchial or pneumonic disease, cannot but assist 
greatly in the production of that collapse of the pulmonary tissue, which 
has been found of late years to coincide so often with the bronchitis and 
pneumonia of young children, and especially with the former. 

The reason why coryza causes so much difficulty in young children is 
that they persist in the effort to breathe through the nose in spite of the 
obstruction of the nasal passages. They seem to do this instinctively, 
not, apparently, having the power to carry on the act of respiration 
through the mouth, or but for short periods only at a time. The constant 
struggle to force the air through the nose, and the necessarily smaller 
quantity that reaches the lungs, are undoubtedly the two chief causes of 
the symptoms above described as occurring in the coryza of children. 

Severe Coryza begins with sneezing and stoppage of the nostrils, 
soon after which the discharge, which is the pathognomonic symptom of 
the disease, makes its appearance. This consists of serous or mucous fluid 
in greater or less abundance, which is usually of a yellowish color, and 
which, at first thin and without odor, becomes afterwards thicker and often 



56 CORYZA. 

purulent, with a peculiar, unpleasant, but not fetid odor. In other cases, 
on the contrary, and especially when the pseudo-membranous exudation 
is present, the discharge is thin, and often contains small granular par- 
ticles, which seem to be the detritus of the false membrane, while at 
other times it is ichorous or even bloody. When false membrane is pre- 
sent, it can often be seen, upon examination of the nostrils in a strong 
light, to cover the mucous membrane in the form of thin adherent layers 
of a yellowish-white color. The alse nasi, and sometimes the whole ex- 
tremity of the nose, are red and swelled, and the skin, which is tense and 
shining, presents an erysipelatous appearance. The upper lip is generally 
reddened, irritated, swelled, and sometimes excoriated, by the nasal se- 
cretions. 

The respiration is generally difficult, nasal, and snoring. "When the 
nasal passages are nearly or quite filled with the secretions, the child 
being no longer able to breathe through them as in health, is compelled 
to keep the mouth open. This is exceedingly inconvenient to children of all 
ages, as it causes great dryness and stiffness of that cavity, and of the tongue 
and throat, and in very young infants, who instinctively respire almost ex- 
clusively through the nostrils, it is attended with such violent efforts, as to 
be a chief or perhaps sole cause of the fatal termination of some cases. In 
one instance that I saw, the child was seized with attacks of suffocative 
breathing, which threatened fatal asphyxia, whenever the passages became 
much impeded. Under these circumstances the cleansing of the passages 
with a brush would afford complete relief, and, for a time, the little thing 
would appear to be quite well. Finally, however, death occurred in one 
of the attacks of dyspnoea, from sudden serous effusion into the lungs. 
The difficulty of respiration is greater, as I have stated, in proportion as 
the child is younger, and depends on the physiological fact already referred 
to, that at a very early age, respiration is performed almost solely through 
the nostrils, and that the child seems incapable of keeping the mouth 
open, in order to compensate for their closure. I have never observed 
cough except in cases accompanied by angina. Epistaxis occurred in two 
cases of the pseudo-membranous form, in children between three and five 
years of age. The bleeding recurred on several occasions, but ceased so 
soon as the coryza was cured. Infants refuse the breast when the pas- 
sages are much clogged, or suckle with great difficulty and at long in- 
tervals. 

The character of the general symptoms depends much more upon the 
accompanying disease, in older children, than on the coryza itself, and it 
is unnecessary therefore to dwell upon them. In the two infants observed 
by myself, the principal symptoms were, in the case unaccompanied by 
angina, restlessness, weakness, emaciation, dry, harsh, and wrinkled skin, 



DURATION — PROGNOSIS — TREATMENT. 57 

and violent attacks of dyspnoea; and in the other case, in which angina 
was present, there were added to these, fever and somnolence. The 
duration, as observed by myself, in the two cases occurring in infants, 
was between two and three weeks, in the one unattended by other disease, 
and six days in the one accompanied by angina. In the other four cases, 
which occurred in older children, the duration of the attack depended on 
the form and degree of the attendant angina. In one case it became 
chronic, and was accompanied by ulceration of the nasal passages. Rilliet 
and Barthez state that they saw a child two years old die in three days, 
and another of three years in the same time ; but as one of these cases 
was complicated with angina and croup, and the other With pseudo-mem- 
branous angina, it is clear that the rapid death depended rather on the 
accompanying disease, than the coryza itself. 

The prognosis must depend on the age of the child, and the form of 
the attack. Simple coryza is never dangerous except in very young 
infants, and rarely in them. When, however, it occurs in a delicate 
infant, and is accompanied with either sufficient turgescence of the nasal 
mucous membrane, or with enough viscid secretion, to cause a more or 
less complete occlusion of the nasal passages, the effort to breathe through 
the nose, and the diminished quantity of air that reaches the lungs, will 
sometimes give rise to great and dangerous exhaustion, or to partial or 
fatal asphyxia. In older children this form of the disease is never scarcely 
more than an annoyance. 

When simple coryza occurs in connexion with other diseases, whether 
thoracic inflammations, angina, or measles, it always adds, and sometimes 
most seriously, to the difficulties of the patient, since the effort to breathe 
through the obstructed air-passages must assist to exhaust the life-forces, 
while at the same time a certain amount of the blood in the lungs, which 
ought to be exposed at each inhalation to the inspired air, is deprived of 
this necessary contact by the fact that less than the natural quantity of 
air is drawn through the nasal passages at each expansion of the chest. 

The purulent and pseudo-membranous forms of coryza are always dan- 
gerous, whether they occur alone, or as a part of other diseases. The two 
cases of idiopathic membranous coryza in infants that came under my 
observation, both proved fatal. The four cases in older children recovered 
without any difficulty. When they occur in connexion with pseudo- 
membranous angina, or in the course of scarlet fever, the prognosis will of 
course depend very much on that of those diseases. 

Treatment. — Simple coryza requires no treatment in children over 
two years of age, except attention to hygienic conditions. Young children 
may often be preserved from attacks of spasmodic laryngitis and bronchitis, 
by calling the attention of the mother to the strong tendency which exists- 



58 CORYZA. 

during infancy and childhood to the extension of disease, and advising, in 
cases of coryza, that the child should be secluded in the house, or else very 
warmly clothed, if sent out. 

In young infants, even the mildest coryza gives trouble, by obstructing 
the full freedom of the respiratory act, by interfering with the suckling, 
and by the restless and broken sleep which it induces. In such cases, all 
the treatment required is to keep the child warm, and to clear the nasal 
passages, and at the same time lubricate them, by the occasional intro- 
duction of a camel's hair pencil charged with glycerine, or sweet oil. 

When the coryza is more severe, so as to interfere a good deal with the 
respiration, it is necessary to make use of the brush frequently, to ad- 
minister a warm foot-bath once or twice a day, and to give a few drops of 
syrup of ipecacuanha, with sweet spirits of nitre, every two, three, or four 
hours. In such cases, my father has been in the habit, for many years 
past, of directing a flannel cap to be put upon the child, and kept there 
for two or three days ; — a simple, and often most effectual mode of treat- 
ment. The cap should be removed after two or three days, so soon as the 
coryza is relieved, or otherwise the child is apt to become so much accus- 
tomed to it, as to take fresh cold when it is removed. 

In infants laboring under purulent or pseudo-membranous coryza, the 
indications of treatment are to remove the secretions as they collect, and 
to subdue the inflammation of the mucous membrane by which they are 
produced. The first indication may be fulfilled by means of a brush made 
of long camel's hair, by throwing water from a small syringe into the 
nasal passages, or, when the discharges are thin and fluid, by blowing 
strongly into the nostrils, whilst the tongue is depressed by a finger intro- 
duced into the mouth, so as to allow the secretions to pass out of the 
posterior nares into the fauces. 

The second indication is to be fulfilled chiefly by the application of solu- 
tions of alum, nitrate of silver, sulphate of zinc or copper, and by insuffla- 
tions of different substances in powder. The best application is probably 
the solution of nitrate of silver, which may be made of the strength of 
five or ten grains to the ounce, or stronger, to be made use of several times 
a day, with a brush. I have also employed injections consisting of solu- 
tions of alum, of from three to six grains to the ounce. It is recommended 
by Rilliet and Barthez to make insufflations of powdered gum and alum, 
or of gum and calomel in equal parts, several times a day. There is, how- 
ever, it seems to me, an objection to this method of treatment, especially 
in infants, — which is that the powders would necessarily tend to increase 
the obstruction which already exists, to breathing through the nose. It 
has been proposed also to apply a few leeches to the mastoid process, or 
over the frontal sinuses. This might be done in hearty children. 






CASE. 59 

In the form of the disease accompanied with angina, an essential part 
of the treatment must be that of the throat-affection. This will be con- 
sidered in another place. 

Case. — The subject of this case, a male, was born after an easy, natural 
labor, and appeared strong and well, with the exception of a little dis- 
charge of blood from the nose soon after birth and slight coryza, the latter 
of which continued until the child was five weeks old, when it became 
aggravated, and my father was requested to visit the infant. I saw it at 
the same time. It was small and puny ; the skin was harsh, dry, and 
wrinkled, so that the child looked like a little old woman. It was very 
weak, and had constant secretions from the nostrils of thick, dark-colored 
pus. When the discharge collected in sufficient quantity to obstruct 
the passages, the respiration became exceedingly difficult, as the infant 
seemed incapable of breathing through the mouth, and at such moments 
it seemed as though it must die of asphyxia. If the nostrils were cleared 
by any means, by syringing, by the use of a brush, or by blowing into 
them in the manner already described, the respiration would become 
easy and natural, until the discharge collected again, when the same scene 
recurred. During the paroxysms arising from the closure of the nasal 
passages, the child was entirely unable to take the breast, but after being 
relieved, had no difficulty whatever; the mouth was either kept shut, or if 
open, the tongue was observed to be pressed spasmodically against the roof 
of the mouth, so that it was impossible for more than a very small amount 
of air to pass over it ; the respiration was labored, and accompanied by 
a loud snoring or nasal sound. There was no other marked symptom, 
except a nearly constant flatulent distension of the epigastric region. On 
the day before death, the infant seemed better, appeared to have gained 
flesh, and looked more intelligent, so that the mother was greatly encou- 
raged ; but the next day it was seized during one of the paroxysms of suf- 
focation, which did not seem to be worse than many preceding ones, with 
copious discharges of bloody and frothy serum from the mouth and nose, 
and died in about three-quarters of an hour. 

At the post-mortem examination we were not allowed to examine the 
nasal passages or throat. The stomach and bowels were healthy, but 
much distended with gas. The peritoneum was healthy, but contained a 
considerable amount of clear yellowish serum. There was serous effusion 
in both pleural cavities, but no traces of inflammation. The lungs were 
healthy, with the exception of some ecchymosed points, and general infil- 
tration with sanguineous frothy serum. The trachea and bronchia were 
natural. The heart was larger than usual, but healthy in other respects. 



60 DISEASES OE THE LARYNX. 

SECTION II. 

DISEASES OF THE LARYNX. 
GENERAL REMARKS. 

There has been much confusion amongst writers on the diseases of 
children, until w.ithin a few years past, in regard to the diseases of the 
larynx in early life, each one differing from the other in his opinions as 
to the nalure of the several disorders of that organ, and of course as to 
their classification and symptoms. From later and more rigid observation 
it has become clear, however, it appears to me, that there are in fact but 
three diseases of the larynx which deserve to be considered as separate 
and distinct affections; these are simple, ordinary, erythematous inflamma- 
tion of the larynx, unattended with spasm of the glottis, or, as that 
symptom has been emphatically named, laryngismus; simple erythe- 
matous inflammation of the larynx, attended with laryngismus, and called 
most properly spasmodic simple laryngitis, or more commonly simple, 
false, spasmodic, or catarrhal croup; and lastly pseudo-membranous in- 
flammation of the larynx, properly named pseudo-membranous laryngitis, 
and more commonly called true or membranous croup. There is, more- 
over, another disease, of which one of the most marked symptoms is spasm 
of the glottis or laryngismus, attended with a hoop or stridor, which is 
now known by the name of laryngismus stridulus, but which is called also 
Kopp's, or thymic asthma, spasm of the glottis, and croup-like convulsion. 
This disease has often been confounded with the above-named spasmodic 
affections of the larynx, under the common title of croup, or has been sup- 
posed to constitute a distinct disease of the larynx ; whereas now it is well 
known that the laryngismus whence its name was taken, is but one of 
many symptoms that mark the dependence of the disease upon disordered 
action of the reflex portion of the general nervous system. 

I am well aware, also, that some most competent observers describe a 
purely spasmodic affection of the larynx, under the title of spasmodic 
croup, which they believe to be entirely independent of laryngeal inflam- 
mation, and to consist in a mere momentary contraction of the sphincter 
muscle of the larynx, produced by the sympathies which that part holds 
with other parts of the body, and especially with the digestive apparatus. 
As I have never, however, in what has now become a very considerable 
experience in the diseases of children, met with a case of spasmodic croup 
unconnected with more or less evident catarrhal condition of the larynx, 
I am not disposed to risk increasing the confusion already attending this 



SIMPLE LARYNGITIS WITHOUT SPASM. 61 

subject, by making additional and more minute varieties of these affec- 
tions than those above-named. I am quite willing to acknowledge that, 
in some cases of simple spasmodic croup, the amount of catarrhal inflam- 
mation of the larynx is slight, and that the symptoms of digestive disorder 
are very strongly marked, but in not a single instance of croup that has 
come under my notice, have I ever had reason to suppose that the croupal 
symptoms were dependent solely on simple spasm of the glottis, (caused 
by some distant irritation), unattended with inflammation of the laryngeal 
mucous membrane. In all such cases that I have met with, it has seemed 
to me that the condition of gastric, intestinal, or bilious disorders, might 
be explained in one of two ways. Either the disorder of the digestive 
function has rendered the child unusually susceptible to cold, by having 
diminished its power of resistance to the weather ; or, the derangement of 
the bodily functions caused by the cold has weakened, amongst others, the 
digestive system, and thus brought about various symptoms of gastric or 
intestinal disturbance, or more commonly of indigestion. 



ARTICLE I. 

SIMPLE LARYNGITIS WITHOUT SPASM. 

Definition; Frequency. — This disease consists of simple erythe- 
matous inflammation of the mucous membrane of the larynx, unattended 
with spasmodic closure of the organ. It is sometimes attended with 
ulceration, but is unaccompanied by exudation of false membrane. The 
frequency of the disease, during infancy and childhood, is very considera- 
ble, so much so that not a winter passes without my meeting with a good 
many well-marked cases. 

Predisposing Causes. — The disease occurs at all periods of childhood, 
but seems to be more frequent under than over five years of age. Of sixty- 
two well-marked primary cases that I have met with in which the age 
was noted, fifty occurred in children under, and only twelve in those over 
that age. Of the former class, twelve were under one year, seventeen be- 
tween one and two, nine between two and three, five between three and 
four, and five between four and five. Of sixty-four cases in which the 
sex was noted, thirty-six occurred in boys, and twenty-eight in girls. As 
to the influence of the seasons, it may be stated that it is by far the most 
common in the fall, winter, and spring months. 

The only exciting causes of the disease which appear to have been ascer- 
tained with any certainty, are the action of cold, the positive influence of 
which cannot be questioned ; the inspiration of irritating substances, such 



62 SIMPLE LARYNGITIS WITHOUT SPASM. 

as gases, smoke, powders floatiDg in the air, etc. ; and violent efforts of 
crying. Rilliet and Barthez state that they have twice known erythe- 
matous and ulcerative laryngitis to follow long-continued and violent 
crying; and Billard also cites this as a cause. I am acquainted with one 
case in which a slight attack of the disease appeared to have been brought 
on solely by loud and obstinate screaming. 

The disease is very apt to occur in the course of other maladies, and 
particularly of measles, small-pox, scarlet fever, bronchitis, and pneumonia. 

Anatomical Lesions. — The anatomical alterations may consist of 
simple inflammation of the mucous membrane, with its various effects, or 
of the same changes in connexion with ulceration. The latter class of 
lesions is almost always confined to secondary cases. In the former class, 
the mucous membrane varies in color between a deep rose and violet 
red, which may be either uniform or only in patches. In severer cases, 
the tissue is at the same time softened or roughened, and sometimes 
thickened. When redness, softening, and thickening are present, the 
disease is generally confined to certain parts, and commonly to the epiglottis 
and internal portions of the vocal cords ; but when redness alone exists, it 
usually affects the whole of the larynx, and sometimes extends to the 
trachea. In cases attended with ulcerations, these alterations exist in 
connexion with those already described. The ulcerations are generally 
small, few in number, very superficial, linear in shape, and are almost 
always found upon the vocal cords. They are so slight often as to escape 
observation, unless a very careful examination be made ; and this, perhaps, 
explains the circumstance of so few persons having met with them in the 
simple acute disease. 

Symptoms j Course ; Duration. — The attack generally begins with 
an alteration of the voice or cry. In infants the change in the cry alone 
exists, so that to detect the disease, it is necessary to hear the child cry. 
In older children the same alteration of the cry is present, but there is in 
addition a change of the voice, consisting of various degrees of hoarseness. 
These symptoms may be so slight as to be observed in the cry only when 
it is strong and forcible, and in the voice so as to strike only the ear of one 
accustomed to be with the child; or they may be so marked as to be heard 
in the faintest cry that is uttered, and so as to be evident in the voice in a 
moment to the most careless observer; or there may be complete aphonia. 
They are often intermittent in this form, and are generally most marked in 
the after part of the day and during the night. Simultaneously with this 
symptom, or very soon after, cough occurs. This is generally hoarse and 
rough, and early in the attack, dry; at a later period it usually becomes loose, 
and as this occurs loses its character of hoarseness. The frequency of the 
cough is variable, but usually moderate ; as a general rule it is most frequent 



SYMPTOMS. 63 

in the evening, and early in the morning, particularly in infants and young 
children. The disease is almost always preceded and attended with some 
coryza, which, in the early stage, is marked by sneezing and slight incrusta- 
tions about the nostrils, and at a later period, by mucous and sero-mucous 
discharges. The respiration remains natural, except that it is sometimes 
nasal, and sometimes a little accelerated. There is rarely any fever, or it 
is slight, and occurs only at night. There is no pain in the larynx. In 
some cases, the hoarseness of the cry, voice, or cough scarcely exists, or is 
but slightly marked, and the only symptoms are dry, hard, teasing, and 
paroxysmal cough, which, from its sound, evidently proceeds from the 
larynx, and resembles very much that produced by the tickling of a 
foreign body in the throat. This form of the complaint is very common 
in our city, and, as it occurs chiefly in infants and young children, is par- 
ticularly troublesome at night, by keeping the child awake. It is apt to 
run on for two, three or four weeks, or even longer, occasioning much 
trouble to the parents ; the attack always terminates favorably, unless it 
run into the severe form of spasmodic laryngitis. 

The symptoms of this disease, instead of being of the mild character 
just described, may be much more severe. The cough is more frequent, 
hoarse, troublesome, and painful, from the scraping and tearing sensa- 
tions it occasions in the larynx. The voice is more affected, becoming 
from husky more and more hoarse, though it is very unusual for it to 
become weak and whispering, as in membranous and severe spasmodic 
croup. The respiration is decidedly accelerated, causing slight dyspnoea, 
and there is more or less fever, whieh is most marked usually in the after 
part of the day and in the night. The pulse is more frequent than in 
health, rising to 120 or 130 in the minute; the skin is hot and dry; the 
child is thirsty, restless, and uncomfortable. After a few days usually, 
the cough becomes loose and eas}', and ceases to be painful ; the voice loses 
its hoarse tone gradually, the fever disappears, the appetite and gaiety 
return, and the child regains its usual health. 

When the laryngeal inflammation becomes violent in this disorder, so 
as to be attended with considerable swelling of the mucous membrane, the 
case always, according to my experience, assumes the shape of grave spas- 
modic laryngitis. To my remarks upon that disorder, in which I shall 
endeavor to embody what I have learned in regard to violent simple in- 
flammation of the laryngeal mucous membrane in children, I must refer 
the reader for further information on this point. 

In nearly all the cases of this form of laryngitis that have come under 
my observation, I have found, upon examining the fauces, more or less 
decided inflammation of the tonsils, soft palate and pharynx. In cases 
following a rather chronic course, from two to four or six weeks, which 



64 SIMPLE LARYNGITIS WITHOUT SPASM. 

arc rarely accompanied by fever or hoarseness, except at the invasion, and 
sometimes in the evening, the pharyngeal mucous membrane presented a 
roughened, thickened appearance, and the tonsils and uvula were more or 
less enlarged and tumefied. 

The duration of the disease varies according to its form and the circum- 
stances under which it occurs. When primary, it lasts usually from a 
few days to one or two weeks, but when it becomes chronic, as I have 
known to happen in several instances, it has lasted from two to four or six 
weeks. The duration of secondary cases depends, of course, upon that of 
the disease during which they occur. 

Diagnosis. — The diagnosis of simple laryngitis is very easy. The 
hoarseness of the cry, voice, and cough, the redness of the mucous mem- 
brane of the pharynx, and the absence of general symptoms, will distin- 
guish it from any other affection. In somewhat severer cases of this form, 
in which the cough is more frequent and harassing, the general symptoms 
more strongly marked, and the respiration somewhat hurried and oppressed, 
the attack may at first view present the appearances of bronchitis or pneu- 
monia. The absence of the physical^ signs of these affections, will show at 
once by negative evidence, the true nature of the case. 

In some cases in which there is little or no hoarseness of the voice or 
cough, the symptoms strongly resemble the early stage of hooping-cough. 
I have met with five instances, in which it was difficult not to believe for 
two and three weeks, that the attack was really one of that disease. In 
one of these the resemblance was so close, that for several days there was a 
distinct hoop during the fit of coughing, with vomiting at the close of the 
paroxysm. The grounds for deciding that the case alluded to was not one 
of pertussis were that the attacks came on like laryngitis, after measles, 
and that the paroxysms occurred only at night. In the other cases 
a correct diagnosis was arrived at only by attention to the state of the 
fauces, which are almost always more or less inflamed and thickened in 
laryngitis, whilst they are not so in pertussis, and by watching the pro- 
gress of the sickness. 

Prognosis. — The prognosis is always favorable in the mild form of the 
disease. I have never known of a fatal instance. 

Treatment. — The treatment of this form of laryngitis ought to be very 
simple. Seclusion in a warm room, careful management of the clothing, 
slight reduction of the diet if there be any fever, a foot bath at night of 
simple water, or of water containing a little mustard, the application of some 
slightly stimulating liniment to the front of the neck and throat twice 
a day, and the occasional internal administration of some gentle expecto- 
rant and anodyne dose, constitute all that is necessary in the great majo- 
rity of cases of this kind. The best internal remedies are a few drops of 



TREATMENT. 65 

syrup of ipecacuanha, with paregoric, laudanum, or solution of morphia, 
given every evening as the child is put to bed, or occasionally through the 
■day also, if the cough is troublesome. A combination of syrup of seneka 
with that of ipecacuanha, will often be found very serviceable. 

In the more chronic cases, in which a slight degree of laryngeal inflam- 
mation keeps up a troublesome and frequent cough, without affecting, 
more than very slightly, the general health of the patient, it will be found 
that the best remedies are carbonate or nitrate of potassa, with syrup of 
seneka or ipecacuanha, and opium, and the application of a nitrate of 
silver solution to the fauces. The following prescription is one I have 
often used with much advantage in children of four or five years old : — 

R — Potass Carbonat., ^i. 

Tinct. Opii, gtt. xlviii. 

Syrup. Senegre, ^ii. 

Syrup. Tolutani, ^vi. 

Aquce Fluvial., gii. — M. 

Ft. Mistura. 
Dose, a teaspoonful three times a day. 

In a number of cases of this kind, I have obtained more benefit from 
touching the fauces twice a day with a solution of nitrate of silver, of from 
five to ten grains to the ounce, than from any internal remedies. In ap- 
plying the wash, the pencil or sponge used ought to be pushed low into 
the pharynx, in order to come as near as possible to the margin of the 
glottis. Where the cough is very troublesome, a small blister over the 
larynx, or the application twice or three times a day, of a mustard plaster, 
will be found very useful. 



ARTICLE II. 

SPASMODIC SIMPLE LARYNGITIS, OR SPASMODIC OR FALSE CROUP. 

Definition ; Synonymes ; Frequency; Forms. — Spasmodic laryn- 
gitis is a disease of the larynx, almost peculiar to children, consisting of 
i simple ordinary inflammation, without pseudo-membranous exudation, 
I of the mucous membrane of that organ, and attended with spasmodic 
contraction of the glottis, or laryngismus, occasioning violent attacks of 
threatened suffocation. 

It is the disease commonly called in this country croup, or, by those 

5 



66 SPASMODIC SIMPLE LARYNGITIS. 

who make the distinction between it and pseudo-membranous laryngitis 
or true coup, spasmodic croup. It is known also by the names of false or 
pseudo-croup. I prefer the term spasmodic laryngitis, because it is 
expressive of the essential characters of the disease. It is the stridulous 
laryngitis of Guersent and Valleix ; the stridulous angina of Bretonneau ; 
the acute asthma of infancy of Millar j and the spasmodic croup of Wich- 
mann, Michaelis, and Double. It is not the laryngismus stridulus 
described by the English authors, Kerr, Ley, and Marsh, which is the 
same as the thymic, or Kopp's asthma of the Germans, and spasm of the 
glottis of the French. It is called by Dr. Wood, in his work on practice 
of medicine, catarrhal croup. 

Spasmodic laryngitis is one of the most frequent of the diseases which 
occur during childhood in this country. It is so common in this city, 
that almost all mothers who have had any experience in sickness, keep 
some remedy for it in their houses, which they are in the habit of resort- 
ing to upon their own judgment. 

During the last seven years I have had under my charge eighty-nine 
cases of the disease, of which I have kept an accurate record, and a num- 
ber of other cases of which I have no written account. Of the eighty- 
nine cases, seventy-three were of the mild, and sixteen of the severe 
form. 

I shall describe two forms or degrees of this disease, the mild and the 
severe. Without this distinction it would be impossible to give an accu- 
rate account of the disorder, since the cases differ so much in severity as 
to render them almost as much unlike as though they were two distinct 
affections. Moreover, while the mild form is widely different from mem- 
branous or true croup in many of its most important symptoms, the severe 
form, on the contrary, resembles it so much as to demand often very nice 
powers of observation to make the distinction, and yet the distinction 
between the two forms of simple and membranous croup, is one of very 
great consequence to the patient, since the prognosis and treatment are 
widely different in the two diseases. 

Predisposing Causes. — The disease is much more common at some 
ayes than others. It occurs most frequently during the period of the 
first dentition, being more common during the second year of life, which 
is the time of greatest activity of the first dentition, than in any other year, 
though it is often met with also in the third and fourth years. In the 
fifth year it still occurs occasionally, in the sixth and seventh it becomes 
rare, and after the seventh I have seen it but once. Of eighty-six cases 
of the disease that I have attended, in which the age was noted, eight 
occurred in the first year of life, twenty-nine in the second, eighteen in 



CAUSES — ANATOMICAL LESIONS. 67 

the third, seventeen in the fourth, nine in the fifth, two in the sixth, two 
in the seventh, and one in the eighth. 

It is said to be more frequent in boys than girls, and this seems borne 
out by my own experience, since of the eighty-six cases, forty-eight 
occurred in boys, and thirty-eight in girls. 

Spasmodic croup occurs usually as a sporadic disease, but is said by 
some authors to prevail at times as an epidemic. I have never had any 
reason to suppose that it was strictly an epidemic like membranous croup, 
which appears to a considerable extent in some years, and in others is 
scarcely seen. I believe rather that the unusual prevalence of spasmodic 
laryngitis at certain periods, in comparison with others, depends on the 
fact, that certain states of the weather or season predispose or excite to it 
in a greater degree than usual, and thus occasion a large number of 
children to be attacked with it. 

It is generally believed to be hereditary in certain families, and of 
this I myself have no doubt. I am acquainted with one family in this 
city, in which the children for three generations were extremely liable to 
it; with another, in which the grandmother and grandchildren were 
frequently attacked ; and with a third, in which the father and children 
showed the same predisposition in the most marked manner. The idea 
is, moreover, entertained by many people in this community. 

The natural constitution of the child does not seem to have much 
influence upon the liability to the disease ; it occurs indifferently in the 
weak and strong. I have no doubt, however, that there are certain tran- 
sient conditions of the health which do affect the liability to it, since it 
has long . been remarked that disturbances of the digestive functions 
frequently invite it, and since I have often myself found it most apt to 
attack those who are liable to it, when they happen to be laboring under 
bilious disorders or indigestions. It is most common during cold 
weather. 

Exciting Causes. — By far the most frequent exciting cause is the 
action of cold ; either the passage from a warm into a cold atmosphere, 
or prolonged exposure to cold. It has been known on several occasions 
to follow long-continued crying, doubtless from inflammatory action set up 
in the larynx, by the overstraining of the muscles and vocal cords of that 
organ. I was assured, some time since, by a very intelligent woman, that 
her little daughter had, at the age of two years, a well-marked attack of 
croup, after a severe and long-continued fit of crying from some contrariety. 
Anatomical Lesions. — Mild cases of spasmodic laryngitis are so 
rarely fatal, as to leave us in some doubt as to the character of the ana- 
tomical lesions, or whether there are indeed any perceptible alterations of 
the tissues. I have never myself met with a fatal case of this form, and 



68 SPASMODIC SIMPLE LARYNGITIS. 

am therefore unable to give any personal account of the condition of the 
larynx, though I have never doubted, from the nature of the symptoms, 
the hoarseness, the dry cough, which afterwards becomes loose, and the 
whole aspect of the disease, that the anatomical condition of the affected 
organ must be one of slight inflammatory hypersemia. In some cases, 
however, that have been examined, a little mucus in the larynx, and slight 
redness have been found, while in others no change has been detected. 
Dr. Wood {Treat, on the Prac. of Med., vol. i., p. 779) accounts for this 
absence of morbid appearances in the following plausible manner : " In 
some rare instances, no signs of disease are discovered in the mucous mem- 
brane, and the patient has probably died of spasm, consequent upon high 
vascular irritation or congestion, the marks of which disappear with 
life." 

Crises of severe spasmodic croup have not unfrequently proved fatal, 
and the anatomical alterations of this form of the disease have therefore 
been well ascertained. These alterations consist of either simple inflam- 
mation of the laryngeal mucous membrane, or of inflammation attended 
with ulceration. When the inflammation is simple, the membrane is 
changed in color, either uniformly or in spots, to a deep rose or dark red 
tint. This may be the only alteration, or the tissue may be found also 
softened or roughened and thickened. When the redness, thickening, 
and softening are all present, these appearances are usually confined to 
certain parts, and particularly to the epiglottis and vocal cords, but when 
redness alone is present, it generally affects the whole of the larynx, and 
may extend to the trachea. To the alterations just described are sometimes 
added, as was stated above, ulcerations. These are commonly small, few 
in number, of a linear shape, and are usually seated upon the vocal cords. 
They are so slight as to escape observation, unless carefully looked for. 

Symptoms; Duration. — The invasion of the mild form of spasmodic 
croup is generally very sudden, for though it is often, perhaps in the 
majority of cases, preceded for a few hours or a day or two by slight 
coryza, hoarseness, and cough, these symptoms are seldom noticed at the 
time, and the child is not supposed to be sick until seized with the 
paroxysm of suffocation, which is pathognomonic of the disease. This 
occurs in much the larger number of cases during the night, and very 
generally wakes the child from sleep. Of sixty-four cases observed by 
myself, in which the time of the attack was noted, it occurred in the 
night in sixty-two, whilst in two it came on in the afternoon. The 
period of the night at which it takes place is very irregular, but it is much 
more apt to be before than after midnight, as is shown by their fact, that 
of forty- two cases in which this circumstance was ascertained, the attack 
was before midnight in thirty, and after in twelve. This agrees 



" 



SYMPTOMS. 69 

closely with the statement of Rilliet and Barthez, that it has been ob- 
served most frequently at eleven in the evening. The duration of the 
attacks varies considerably, and depends a good deal upon the treatment 
employed. They may last from a few minutes to several hours, but are 
seldom less than half an hour or an hour. The number of the attacks 
also varies. In some cases there is but one, though very generally there 
are several. When the attack occurs early in the night, it is very apt to 
recur again towards morning, and, unless means of prevention are used, 
on the following night also, and even, though this happens much more 
rarely, on the third night. As a general rule, the first attack is the most 
severe. 

When the paroxysm comes on, the child is wakened from sleep by the 
sudden occurrence of symptoms apparently of the most alarming and 
dangerous character. These consist of loud, sonorous, and barking cough ; 
of prolonged and labored inspirations, accompanied by a shrill and 
piercing sound, to which the term stridulous is applied ; of rapid and 
irregular respiration, amounting often to violent dyspnoea, or seemingty 
impending suffocation : the child, alarmed and terrified at its condition, 
and at the fright of those around, its countenance expressive of the 
utmost anxiety, cries violently between the attacks of coughing, and begs 
to be taken on the lap, or sits up or tosses itself upon the bed, struggling 
apparently with the disease, which seems for the moment to threaten its 
very existence. The voice and cry are hoarse, and sometimes almost 
extinguished during the height of the paroxysms, but becomes distinctly 
audible, and often nearly natural, in the intervals between them ; differ- 
ing in this respect from pseudo-membranous croup, in which they remain 
permanently hoarse or whispering. I have never heard, in this disease, 
the whispering voice and the short smothered cough of true croup. The 
face, head, and neck, are at first deeply flushed, and as the paroxysm 
becomes more violent, assume a dark livid tint, which afterwards passes 
into a deadly paleness, if the attack be long continued. These changes 
in the coloration depend upon the arrest of the respiratory function and 
a consequent partial asphyxia. The pulse is frequent during the paroxysm, 
and the skin heated. After a longer or shorter period, generally from 
half an hour to an hour, the respiration becomes more tranquil; the 
stridulous sound disappears entirely, unless the child be disturbed and 
made to cry, when it again becomes distinct ; the cough is less frequent 
and less boisterous, and the child generally falls asleep. The attack is 
very apt to recur towards morning, as has been stated, and if not then, 
the following night. The patient often seems perfectly well the day 
after the first paroxysm, with the exception, perhaps, of slight cough. 
This is no reason, however, for supposing that the disease will not return 



70 SPASMODIC SIMPLE LARYNGITIS. 

in the course of the second night, which is almost sure to happen, unless 
measures be taken to prevent it. The cough generally continues for a 
day or two, but soon loses the peculiar character expressed by the term 
croupal ) it becomes less frequent and more loose, and the child is com- 
monly well again in two or three days. Sometimes, however, the cough 
lasts for several days, becoming gradually less frequent, until at last it 
ceases entirely. 

There is very little fever in mild cases, for though the pulse is accele- 
rated and the skin warm during the paroxysm, these symptoms disappear 
very soon after that is over. In more severe cases, on the contrary, there 
may be considerable fever, the pulse becoming frequent and full, and the 
skin hot. The febrile movement is most apt to occur after the first pa- 
roxysm, as a consequence, apparently, of the slight catarrh which remains 
after the attack. 

In the few fatal cases on record, the paroxysms have generally become 
more frequent and more violent by degrees, and death has occurred from 
suffocation. In other instances, death has been the result of prostration, 
which itself has probably depended on imperfect hsematosis. 

Recurrences of the disease are very common, children sometimes having 
several attacks in a single winter. This is not the case in true croup. I 
have never known a child to have a second attack of that disease. 

The severe form of spasmodic laryngitis may begin as such or result 
from an aggravation of the mild form ; or, the case may commence as one 
of simple laryngitis without spasm of the glottis, and as the intensity 
and extent of the laryngeal inflammation increase, it may assume all the 
features of the form under consideration. Whatever be the mode of 
onset of the case, this form of the disease sets in with hoarse, frequent 
cough, difficult respiration, restlessness, and more or less violent fever, 
symptoms which almost always become severe for the first time at night, 
and usually between early evening and midnight. During the night the 
symptoms increase in severity ; the respiration is frequent and difficult, 
and, after a time, attended with the stridulous sound in inspiration and 
expiration caused by narrowing of the glottis ; the cough is hoarse, dry, 
and croupal, and unattended with expectoration; the voice becomes 
hoarse; fever appears, the pulse becoming full and frequent, the skin 
hot and dry, and the face flushed. These symptoms persist, with greater 
or less severity, throughout the night, while from time to time, they 
increase to such an extent as to seem to threaten suffocation, resembling 
then exactly the paroxysms described as occurring in the mild form of 
the disease. They usually subside, however, very decidedly towards 
morning, the breathing becoming easier, the stridulous sound less loud, 
or ceasing altogether, the fever diminishing, and -the patient becoming in 



SYMPTOMS — DURATION. 71 

all respects much more comfortable. This amelioration of the child's 
condition often continues until towards evening, when again the same 
symptoms as of the night before recur. In other cases the disease 
scarcely subsides at all for two, three, or four days, but continues through- 
out the day and night, to exhibit the same symptoms as have been 
described above. In cases of this kind, which are not at all rare, the dis- 
ease assumes many of the alarming and dangerous characters of pseudo- 
membranous laryngitis or true croup, and it becomes very difficult often 
to distinguish between the two. If no favorable change take place, the 
dyspnoea becomes so violent as to threaten suffocation ; the cough is rare 
and short ; the voice is a mere whisper, or is lost entirely ; 'the pulse 
becomes small, extremely rapid and thready; the countenance, at first 
livid and congested, assumes a pale, cadaveric appearance ; the features 
are contracted ; the child becomes comatose or delirious, and death 
occurs from slow asphyxia, or sometimes in an attack of general convul- 
sions. 

In favorable cases, on the contrary, the dyspnoea, and especially the 
stridulous sound, diminish ; the cough becomes ldose, less hoarse, and 
loses its croupal character j expectoration of mucous sputa takes place in 
older children, whilst in younger, the loose gurgling sound produced by 
the discharge of the sputa into the fauces, is heard at the termination of 
each cough; the voice becomes clearer and stronger; the fever dimi- 
nishes ; the child regains its spirits and disposition to be amused ; and 
soon all dangerous symptoms have disappeared, and the recovery is esta- 
blished. 

In nearly all the cases that have come under my observation, I have 
found, upon examining the fauces, more or less decided inflammation of 
the tonsils, soft palate, and pharynx. 

The duration of the severe form of spasmodic croup depends on the 
violence of the attack, and on the mode of treatment. When the treat- 
ment is begun with from an early period, the disease is much sooner 
overcome than when allowed to run on for some time without remedies. 
In cases of moderate severity, the violence of the symptoms usually sub- 
sides after thirty-six or forty-eight hours. In more violent cases, on the 
contrary, the symptoms seldom subside definitively before the third, fourth, 
and not unfrequently the fifth day. In no case that has come under my 
observation, has the disease continued to present dangerous symptoms 
after the fifth day, unless, as not unfrequently happens, the inflammation 
spreads to the bronchia or tissue of the lungs, producing bronchitis or 
pneumonia. But, even after the signs of severe laryngeal inflammation 
have disappeared, there almost always remains for several days longer, 
some cough and huskiness of the voice, marking that the mucous mem- 



72 



SPASMODIC SIMPLE LARYNGITIS. 



brane of the larynx has not yet regained completely its healthy condition. 
The disease is said to have proved fatal in twenty-four hours. 

Nature of the Disease. — Authors hold very different opinions as to 
the nature of spasmodic laryngitis. By Underwood, Dewees, and Eberle, 
it is confounded with membranous laryngitis, they making no distinction 
between false or catarrhal, and true or membranous croup. Dr. Cheyne 
(Cyclop. Pract. Med., Art. Croup), treats of the two affections as one and 
the same disease, differing only in their degree of violence. Dr. Copland 
(Did. of Pract. Med., Art. Croup), describes spasmodic croup as a variety 
or modification of true or membranous croup. He supposes that the 
modifications of true croup are attributable to " the particular part of the 
air-passages chiefly affected, to the temperament and habit of body of the 
patient, and the intensity of the causes." It seems to me, however, that 
these views, as to the nature of the two diseases, are not correct, and I am 
induced by personal observation to regard them as distinct affections, 
which may, in the great majority of cases, be distinguished from each 
other at a very early stage, by a careful observer. The comparative 
fatality of the two diseases alone is sufficient to establish a wide difference 
between them. Thus, of sixteen cases of the pseudo-membranous form 
that I have seen, eight died ; while of eighty-nine cases of the spasmodic 
form of which I have kept a record, and a considerable number of which 
I have no notes, not one was fatal. M. Guersent states that of ten cases 
of the former disease, scarcely two escape ; while of upwards of a hundred 
of the latter that he has seen, not a single one was fatal. (Diet, de Med., 
t. ix. p. 365.) 

The different effects of treatment in the two affections also point out a 
wide difference in their nature. True croup is almost inevitably fatal, 
unless attacked at a very early period by the most energetic remedies, 
bloodletting, calomel, and emetics, while the mild spasmodic form seldom 
resists the exhibition of an emetic, a warm bath, or of nauseating doses of 
ipecacuanha or antimony, and the severe form, though of a most threat- 
ening appearance, almost always yields to the proper employment of an 
efficient antiphlogistic treatment, aided by the use *of nauseants and 
emetics. When we add to these circumstances, the differences in the 
anatomical alterations in the two diseases, the difference in the mode of. 
invasion, in the cough, voice, cry, fever, duration of the attack, and state 
of the constitution, all of which will be carefully described in the remarks 
on diagnosis, I do not see how we can resist the conclusion that they are 
two distinct disorders, and not, as has generally been asserted by English 
writers, degrees or modifications of the same. 

I believe, therefore, that mild spasmodic laryngitis is a disease con- 
sisting in slight inflammation of the mucous membrane of the larynx, 



NATURE OF THE DISEASE — DIAGNOSIS. 73 

attended with violent spasmodic contraction of that organ, or, as that 
condition has been called of late, laryngismus. The spasm of the laryn- 
geal sphincter seems to be the result of a disordered action of the excito- 
motory innervations of the part, the irritant, which is productive of the 
morbid innervation, being, in all probability, the slight inflammation of 
the laryngeal mucous membrane, which has been already stated to consti- 
tute one element of the malady. The nervous element predominates in 
the early part of the attack, but towards the conclusion, the spasmodic 
symptoms disappear entirely, and we have left only those which depend 
on the laryngeal inflammation. 

In severe cases of the disease we have the same element of laryngeal 
spasm, or laryngismus, coincident with, and produced by, a much more 
intense and dangerous inflammation of the mucous membrane of the part 
than exists in the mild form. 

Diagnosis. — Unquestionably the disease with which spasmodic laryn- 
gitis is most likely to be confounded is pseudo-membranous laryngitis, or 
true croup. There is very little difficulty, however, in distinguishing the 
mild form of spasmodic croup from true croup, whilst in regard to the 
severe form, it may be safely stated, that the distinction cannot, in some 
cases, be made with positive certainty, except by watching the course of 
the sickness. 

Mild cases of spasmodic croup may be distinguished from membranous 
croup by a comparison of the different symptoms as they arise. The most 
important of these are : the invasion, in one sudden and almost invariably 
in the evening or night, in the other, slow and creeping, the paroxysm 
occurring indifferently day or night; the cough, in one hoarse and bois- 
terous, in the other hoarse and frequent at first, but rare and smothered 
towards the end ; the voice, in one hoarse, but never scarcely whispering, 
and if so, only during the height, in the other hoarse at first, and soon 
permanently whispering or entirely lost; the cry, in one hoarse and stridu- 
lus only at the moment of the paroxysm, in the other permanently so ; 
the respiration, in one stridulous and difficult only during the paroxysm, 
and in the interval perfectly natural, in the other, at first natural, be- 
coming by degrees permanently stridulous, and attended by the most 
violent dyspnoea, with remarkable prolongation of the expiration; the 
fever, in one very slight and generally observed only during the nocturnal 
paroxysm, in the other much more considerable and permanent; and 
lastly, the duration, in one seldom more than two or three days, in the 
other rarely less than six, and very often eight or ten days. M. 
Trousseau states that the hoarse-sounding, croupal cough, is not a sign 
of the presence of exudation in the larynx, but rather of its absence ; 
but, " when the cough, croupal at first, becomes less and less frequent, 



74 



SPASMODIC SIMPLE LARYNGITIS. 



and ends with being nearly insonorous with suffocation, there is true 
croup, that is to say, with plastic exudation in the larynx." This is 
precisely my own experience. The rare, insonorous cough of M. Trous- 
seau, is the condition which I have expressed by the term smothered. 

In order to render the diagnosis still clearer, I add the following table, 
which is altered from one given by Rilliet and Barthez. 



MILP SPASMODIC LARYNGITIS. 

Begins with coryza, and hoarse 
cough, or more frequently -with a sud- 
den attack of suffocation in the night. 
Fauces natural, or merely slight red- 
ness, as in simple angina. 



After the paroxysm, the child seems 
well ; the fever disappears, or is very 
slight. Voice natural or only slightly 
hoarse ; not whispering. 

If the paroxysm returns, it is during 
the folio-wing night, and it is less severe ; 
the hoarseness disappears ; the cough 
becomes loose and catarrhal. 

Duration seldom more than three 
days. 

Very rarely fatal. 



PSEUDO-MEMBRANOUS LARYNGITIS. 

In epidemic form, begins as pseudo- 
membranous angina. In sporadic form, 
invasion of slight hoarseness for a day 
or two. There is fever, increase of the 
hoarseness, with hoarse, croupal cough; 
in half the cases, pharyngeal exudation, 
and a little later paroxysms of suffoca- 
tion. 

The fever continues ; stridulous re- 
spiration ; prolonged and difficult ex- 
piration ; cough hoarse and smothered ; 
voice hoarse and whispering. 

The dyspnoea and suffocation in- 
crease ; the voice and cough are smo- 
thered or extinguished; stridulous re- 
spiration persists. 

Duration seldom less than five or six. 
The hoarseness continues for several 
weeks. 

Fatal in the majority of the cases. 



The only real difficulty in the diagnosis is the distinction between the 
grave form, and pseudo-membranous laryngitis or true croup uncon- 
nected with angina; and this, it would appear from all evidence, cannot 
in some cases be made with absolute certainty. The only certain and 
indubitable sign by which to distinguish them, is the presence of false 
membranes in the expectoration. The existence of this symptom is proof 
positive of pseudo-membranous disease, but its absence is no proof that 
the case must be one of simple inflammation j for, even though the mem- 
brane has been exuded in large quantities within the larynx, it is not 
always thrown off by the effort of coughing or vomiting. To show the 
difficulty of the diagnosis, I will cite the case quoted by M. Valleix (Loc. 
cit. t. i. p. 211) from M. Hache, of a child supposed to be laboring under 
true croup, who was sent to the Children's Hospital in Paris, in order to 
have the operation of tracheotomy performed. The absence of false mem- 
brane in the expectoration, and a slight remainder of clearness of the 
voice, occasioned the suspension of the operation. The child died, and no 



DIAGNOSIS. 75 

pseudo-membrane whatever was found in the larynx. The onl} 7 lesions 
were moderate redness of the mucous membrane, without tumefaction, and 
without narrowing of the glottis ; so that the fatal termination must be 
ascribed to spasmodic constriction of the glottis, or to tumefaction of that 
part which had disappeared after death. 

Nevertheless, though the diagnosis is difficult, it can generally be made 
out with considerable certainty by attention to the following points. The 
pseudo-membranous form of the disease is often preceded or accompanied 
by the presence of false membranes in the fauces, which is not the case in 
spasmodic simple laryngitis ; the symptoms of invasion of the former disease 
are less acute than those of the latter, the fever being less violent, and the 
restlessness and irritability less marked, than is usual in the simple affec- 
tion, in which the general symptoms are severe from the first. The hoarse- 
ness of the voice and cough follow a different course in the two diseases ; 
the progress of these symptoms being slow and gradual in the mem- 
branous, and much more rapid in the severe spasmodic form. The 
fever is violent throughout the attack in the severe spasmodic disease, 
whilst in the other form it seldom reaches a high degree of intensity. 
Lastly, the presence of portions of false membrane in the expectoration, 
in connexion with the laryngeal symptoms, affords positive evidence of 
the existence of true croup. 

Of the characters just enumerated as likely to aid us in distinguishing 
between severe spasmodic and true or membranous croup, I wish to call 
the reader's attention in greater detail to two, the first of which is the 
condition of the voice. This is, I have no doubt, much the most import- 
ant single symptom. In membranous croup, the voice begins by being 
hoarse, but soon becomes weak, so that after the disease has lasted three 
or four days, it changes from hoarse to whispering ; it becomes, in fact, 
suppressed. Now in severe spasmodic croup, the voice is hoarse at first, 
and becomes more so as the disease goes on, but it very rarely becomes whis- 
pering as in true croup, but almost always retains a good volume, so that 
when urged, the child can speak out loudly. This is never the case in the 
membranous disease, for, as the fibrinous exudation is deposited on the 
vocal cords and in the ventricles of the larynx, it suspends almost entirely 
the functions of those parts, and the voice is more or less completely 
suppressed. The remarks just made in regard to the voice, will apply also 
to the cry, which should be carefully studied in young infants. 

Another symptom that ought to be closely scrutinized, is the stridor. 
This is, as might be expected, more marked in all its features, in true 
than in false croup, since in the former it depends on a permanent and 
considerable obstacle to the passage of the air through the larynx. That 
tube is, in fact, completely coated over upon its internal superficies, with a 



76 SPASMODIC SIMPLE LARYNGITIS. 

more or less thick false membrane, which reduces materially its calibre, 
and impedes to a greater extent, the passage of air, than does the mere 
inflammatory turgesceuce and swelling of the mucous membrane of the 
organ in severe spasmodic croup. On this account, therefore, the stridor 
in the respiration is louder, shriller, more persistent, more marked in the 
expiration, and attended with greater effort of the respiratory muscles to 
overcome the obstacle to the passage of the air in membranous than in 
severe spasmodic croup. 

To conclude, there is in membranous croup, a slow, steady, and unre- 
lenting progression of the symptoms, which is not observed in the spas- 
modic disease. From hour to hour, from day to day, we can perceive, so 
to speak, from the gradual and steady march of the disease, that a foreign 
body in the form of a fibrinous moulding, is being spread slowly over the 
cavity of the larynx. In severe spasmodic croup, on the contrary, the 
course of the symptoms is less regular; paroxysms of suffocation occur as 
in true croup, but when these are over, the child is often quite comfortable, 
the symptoms indicating a much less considerable permanent mechanical 
obstruction than in the other affection. 

Spasmodic laryngitis may be mistaken also for laryngismus stridulus. 
The manner in which it is to be distinguished, will be described in the 
article on that disease. 

Prognosis. — Spasmodic simple laryngitis is very rarely a fatal disease. 
Of its two forms, there can be no doubt that the severe is much more 
dangerous than the mild, since in the former the patient labors under 
acute inflammation of the larynx, as well as under spasm of that organ ; 
whilst in the latter, the amount of inflammation is so very slight, as to be 
of little or no consequence, were it not associated with the laryngismus, 
which gives to the disorder its most characteristic features. 

Of 89 cases of the disease of which I have kept an accurate record, 
none proved fatal, though 16 of the 89 were of the grave form. I may 
state also, that I have seen a considerable number of cases, of which I 
have no written account, in none of which was there a fatal termination. 
I have, therefore, never seen a case of croup without false membrane, 
prove fatal. That it does sometimes end unfavorably, however, cannot 
for a moment be questioned. There are various examples of the kind, 
scattered through the medical journals. Killiet and Barthez quote in 
proof of this, two cases from the work of Jurine, in one of which an 
autopsy was made, and no false membrane discovered. Copland (Loc. 
cit.) remarks that in the few cases of the more purely spasmodic forms that 
he has had an opportunity of examining, an adhesive glairy fluid with 
patches of vascularity on the epiglottis and larynx, and a similar fluid in 
the large bronchi, were the only alterations observed. 



PROGNOSIS — TREATMENT. 77 

Great imminence of danger in any case is shown by a high intensity 
of the stridulous sound, especially as heard in the expiration ; by great 
severity of the dyspnoea or suffocation; by lividity or extreme paleness of 
the face; by smallness and rapidity of the pulse; by coldness of the ex- 
tremities; and by delirium or convulsions. 

Treatment. — Guersent (Loc. cit. p. 367, 368) states that demulcent 
and mucilaginous drinks, with stimulating manuluvia and pediluvia are 
the principal means that ought to be employed in the treatment of spas- 
modic laryngitis, or pseudo-croup. He proscribes the use of emetics and 
leeches as unnecessary in most cases, and is of opinion that they have 
come into general use in the management of the disease, in consequence 
of its having been generally confounded with true croup. In a paper on 
croup, by my father, Dr. Charles D. Meigs (Med. Exam., vol. i. p. 398), 
may be found the following statement in regard to the spasmodic variety : 
"The croup sound often ceases entirely, and never returns after the exhi- 
bition of a small quantity of ipecacuanha, or any other emetic substance, 
even when no emesis is produced/' He says in another place, that 
"a foot bath with mustard, and an emetic of ipecacuanha, is in general 
all that is necessary for the cure." 

In giving my own experience in regard to the treatment of this disease, 
I shall speak first exclusively of the mild, and then of the severe form, 
since the measures proper and necessary in the one, are very different 
from those called for in the other. 

Treatment of the Mild Form; Emetics. — The great majority of 
cases will recover perfectly well under the use of emetics alone, or in com- 
bination with warm baths and revulsives. In cases attended with violent 
dyspnoea, hoarse cough, and loud stridulous respiration, the emetic should 
be given until it produces a full effect. In milder cases, in which there 
is merely loud croupal cough, with an occasional stridulous sound, nause- 
ating doses alone will generally suffice. The most suitable emetic is, as 
a general rule, ipecacuanha. The best preparation for children is the 
syrup, of which from twenty to thirty drops may be given to those two 
years of age, to be repeated every ten or twenty minutes until vomiting is 
produced, or until the paroxysm is relieved. In very sudden cases, the 
Syrupus Scilke Compositus, which is more active in its effects in conse- 
quence of the tartar emetic which it contains, might be preferable ; about 
twenty drops of this may be given, and repeated every ten or fifteen 
minutes, until vomiting or the resolution of the paroxysm is obtained ; 
but, in its employment, care should always be observed not to continue it 
for too long a time, lest it produce the injurious effects of tartar emetic. 
When the dyspnoea is very urgent, or when other means fail to produce 
emesis, I have found nothing so effectual as the powdered alum, in doses 



78 SPASMODIC SIMPLE LARYNGITIS. 

of a teaspoonful mixed with honey or molasses. (See treatment of pseitdc 
membranous larynyitis.) 

A simple and good method of treating the paroxysm is that recom- 
mended by my father, in the paper referred to. It is to direct a small 
teaspoonful of powdered ipecacuanha to he diffused in a wineglassful of 
water, of which mixture doses of a teaspoonful are to be given every 
ten, fifteen, or twenty minutes, according to the urgency of the symptoms. 
This is a plan of treatment often resorted to by parents in this commu- 
nity, where the disease is so common, and so well understood, that there 
are few mothers who have several children, and who have had some little 
experience, who do not know how to treat a nocturnal attack of mild 
spasmodic laryngitis. 

After the paroxysm is relieved, it is a good plan to direct five or ten 
drops of the ipecacuanha syrup to be given every two or three hours 
during the following day ; or, if the child seem perfectly well in the 
morning, we may begin with these doses in the middle of the day, and 
continue them until bed-time. By this method, the recurrence of the 
paroxysm during the second night may, I think, often be prevented, and 
the cough is rendered free and loose much sooner than when the disorder 
is left to pursue its natural course. 

Baths. — The warm bath is a very prompt and useful remedy in the 
disease. In all very violent cases, it ought to be resorted to immediately. 
It should be used also whenever the emetic fails to relieve the urgency 
of the symptoms, and in cases attended with much disturbance of the 
circulation. The temperature of the water ought to be about 96° of 
Fahrenheit, when the child is first immersed, to be raised gradually by 
the addition of hot water, to 100° or 102°. The child may remain in 
the bath from ten to twenty minutes. 

Bloodletting. — Depletion can rarely be necessary in spasmodic 
croup. The only cases which would call for it are those in which the 
symptoms tend to assume the features of the grave form, or of pseudo- 
membranous croup. Under such circumstances, the method of treatment 
would be the same as that proper for those affections, to the descriptions 
of which the reader is referred for further information. 

In only two out of the seventy-three cases of this kind that I have 
attended, was depletion resorted to. One of these occurred in a girl, 
six months old, who was leeched in front of the larynx, because the 
action of an emetic and the use of the warm bath had failed to relieve the 
paroxysm. The child was quite well on the following day. The other 
case was that of a boy between two and three years of age, who was bled 
to three ounces on the second night of the attack, on account of the 
violence and obstinacy of the paroxysm. He was much relieved by the 
bleeding, and recovered from that time. 



TREATMENT. 79 

Revulsives. — The only revulsives that it is necessary to employ, are 
mustard foot-baths or mustard poultices applied to the interscapular space; 
and even these are often needless if the emetic be given. Blisters, which 
are recommended by some of the French writers, can only be proper, it 
seems to me, when the symptoms resemble those of the grave form, or of 
true croup. 

Purgatives are required when constipation is present, or when there 
is fever on the second or third days, showing a considerable amount of 
laryngeal inflammation. Under the latter circumstances some mild 
remedy of this class may be resorted to with a view to its evacuant 
effect. I have never had occasion to employ any of the mercurials, and 
believe them to be unnecessary. 

Opium is exceedingly beneficial when the emetic, nauseant, or warm 
bath have failed to relieve entirely, and when a troublesome, croupal 
cough continues after the spasm has been overcome. Laudanum, pare- 
goric, or solution of morphia, in combination with syrup of ipecacuanha 
or hive syrup, or Dover's powder, are the most suitable preparations. It 
is a very good plan to give the child a moderately full dose of this 
remedy, with ipecacuanha, after the violence of the paroxysm has sub- 
sided. It often puts the child to sleep, promotes perspiration, softens 
the cough, and must tend to prevent the return of the spasm. Repeated 
once or twice early in the second night after the first attack, I believe it 
often assists materially to avert the recurring nocturnal paroxysm. 

Treatment of the Severe Form. — This form of spasmodic laryn- 
gitis or croup demands, on account of the rapidity of its progress, and 
its dangerous character, a prompt and active treatment. The remedies 
most to be depended on are bloodletting, calomel, and emetics. 

Bloodletting is recommended by most writers. It should generally 
be resorted to unless contra-indicated by the feebleness of the patient, 
whether this be congenital, or the result of some previous disease. Vene- 
section is preferable to leeching, whenever it can be performed, as the 
latter annoys, distresses, and fatigues the child, and is almost violently 
resisted. The quantity of blood to be drawn must depend, of course, on 
the age and strength of the child. About four ounces may be taken from 
a hearty child of three or four years old. If no visible impression be 
made upon the disease, the operation may be repeated in six or twelve 
hours, though, as a general rule, I have not found it necessary to perform 
a second bleeding. Still, I should not hesitate to repeat it once, or even 
a third time, were the symptoms to continue unabated, and the child not 
seem exhausted by the previous depletion. 

Depletion was employed in six of the sixteen cases seen by myself. In 
one, the subject of which was a girl between five and six years of age, the 



SO SPASMODIC SIMPLE LARYNGITIS. 

dyspnoea and stridulous respiration, with hoarseness of the voice and 
cough, continued for thirty-six hours, and were not relieved until the 
child had been twice bled from the arm to the amount of four ounces each 
time, and once leeched over the larynx. This case presented, in fact, 
most of the features of true croup. In another, in a girl of the same age, 
venesection to four ounces was employed after the symptoms had refused 
to yield to full vomiting by hive syrup. The third case was that of a 
boy between one and two years old, who was bled to three ounces. In 
the three remaining cases, venesection was employed in consequence of 
the severity of the symptoms, and in all proved very serviceable in con- 
trolling the laryngeal obstruction. 

Calomel is often necessary so soon as the real nature of the attack 
is ascertained. Its powerful sedative action upon the circulatory and 
nervous systems, and its specific influence upon local inflammations 
attended with increased proportion of the fibrinous element of the blood, 
as well as experience, indicate the propriety of its employment in this 
disease. A full dose, from two to four grains, may be given at first, in order 
to procure its'purgative action, after which smaller doses, from half a grain 
to two grains every hour or two, should be administered with a view of 
obtaining the aplastic influence of the remedy upon the blood. The last- 
named doses ought to be continued for one or two days, or until the 
violence of the attack is evidently abating. I have generally found that 
the calomel reduces the fever, softens the pulse, diminishes the stridor, 
and loosens the cough, after having been continued for twelve or twenty- 
four hours. In one case, that of a child a year and a half old, in whom 
a very dangerous attack had gone on for four days, unsubdued by bleed- 
ing, active emetics, baths, antimony in small doses, and opium, the 
disease yielded rapidly under the powerful cathartic and sedative opera- 
tion of four grains of calomel, given in doses of a grain every hour. 
"When the calomel operates too much upon the bowels, it should be com- 
bined, if it be necessary to continue its use, with a small quantity of 
opium, in order to prevent this effect. For some years past, I have been 
in the habit, both in this disease and in true croup, when the fever was 
high, of employing the following combination, and, in most instances, 
have found it a most effectual prescription : 

.R — Hydrarg. Chlor. Mit., . . . gr. vi. 

Antimon. Sulphuret. Prsecip., . gr. ss. 

Potass. Nitrat., gr. xii. vel xxiv.— M. 

Ft. in chart., no. xii. 
Dose, one every two hours. 

Emetics are of very great importance in the treatment, though less so 



TREATMENT. 81 

perhaps than in true croup, in which it is essential to cause the rejection 
of the false membrane which obstructs the larynx. Yet they are exceed- 
ingly useful, and sometimes indispensable, in assisting to expel the viscid 
mucus secreted within the larynx, and in relaxing, for a time at least, the 
spasmodic constriction of the glottis, which plays an important part in the 
production of the distressing dyspnoea and suffocation of the disease. They 
act probably also by lessening immediately, or through their influence on 
the circulatory and nervous systems, the inflammation of the larynx. 
They should be used once or twice, or oftener in the day, according to the 
degree of dyspnoea, and the effects they produce. For their choice and 
mode of administration, the reader is referred to the article on true croup. 

Purgatives are required merely to keep the bowels soluble ; they should 
be repeated as may be necessary throughout the disease. The most 
suitable are castor oil, rhubarb, magnesia, or small doses of the powder of 
jalap combined with calomel. 

Expectorants are useful after the violence of the disease has been 
moderated by more energetic remedies. They may consist of small doses 
of ipecacuanha, of antimonial wine and sweet spirits of nitre, fractional 
doses of tartar emetic, decoction of seneka, snake-root, Coxe's hive syrup, 
or carbonate of potash. 

Opiates are often necessary and serviceable in calming excessive rest- 
lessness, and in allaying the violence of the suffocative attacks, which de- 
pend, in good part, as has been stated, on spasm of the glottis. The 
most suitable are Dover's powder or some other preparation of opium, or 
small doses of belladonna, or hyoscyamus. 

A warm bath at 97° or 98°, employed once or twice a day, and continued 
for a period of ten or fifteen minutes, often assists greatly in lessening the 
sufferings of the child, in calming restlessness, and in moderating the heat of 
skin and violence of the circulation, when the latter symptoms are strongly 
marked. The same effects may often be obtained by the use of counter- 
irritants, as sinapisms, mustard poultices, mustard foot-baths, etc. 
Blisters are of doubtful propriety in most cases. Nevertheless, I believe 
that I once saw good effects from the application of a small one over the 
larynx and trachea. 

Hygienic Treatment. — In either form of the disease the child 
should be placed for the time in a warm room, and warmly clothed. If 
old enough, it ought to be kept as much as possible in bed during the 
paroxysm. If so young as to prefer the lap of the nurse, it should be 
clothed in a long loose wrapper in addition to its usual night-dress. It is 
very important to confine the child for one or two days after the occurrence 
of the nocturnal paroxysms to a warm room, in order to prevent, if possible, 
an attack on the second or third nights. The diet must be simple and 

6 



82 SPASMODIC SIMPLE LARYNGITIS. 

of easy digestion, so loug as there is any disposition to recurrence of the 
disease. It may consist of preparations of milk, of bread, rice, or of thin 
chicken or mutton water. Meat and most vegetables had better be 
avoided, until the convalescence is fairly established. 

Prophylactic Treatment. — It is certain that much may be done by 
a wise attention to physical education, to prevent attacks of the disease in 
children who have shown a liability to them. I would strongly recom- 
mend, with this view, attention to the following advice given by M. 
Gucrsent, who says (Loc. cit. p. 381) : " It is possible to a certain ex- 
tent, to prevent attacks of pseudo-croup, by fortifying the constitutions of 
children, by means of exposing them well clothed to a dry and elastic 
atmosphere, particularly if they can be kept in constant movement. But 
of all the precautions which have been found unquestionably advantageous, 
that which seems most useful is to make them sleep in well-ventilated, 
dry, carefully closed chambers, having a south exposure, and always 
without fire. I have several times been convinced of the utility of this 
habit in families the children of which were subject to this kind of 
catarrh." 

There can be no doubt that the style of dress used for children in this 
country, must occasion many and repeated attacks of croup which might 
just as well have been avoided. The custom is to dress children between 
the ages of one and four or five years, in such a way as to expose the whole 
of the neck and the upper half of the thorax (for the dresses are made so 
low and loose at the shoulders, as to leave the upper part of the chest 
virtually uncovered). The arms are left bare, as are also the legs from the 
knee, or above the knee, to the ankle, so that very nearly half of the cuta- 
neous surface is without covering, and this, too, in the very same rooms and 
temperature in which sit the parents with the body and limbs warmly clothed 
to resist our climate, at all seasons changeable and uncertain, and in the 
winter, very cold. I am perfectly well convinced that this faulty and 
unreasonable system of dress, which is chosen because it is the fashion, or 
in order to harden the child, who, however, invariably puts on warm 
clothing when it comes to years of discretion, will explain in part the 
enormously greater frequency in children than in adults, of the various 
diseases of the air-passages and lungs produced by cold. 

O-ne of the most important means of prevention, therefore, is the adop- 
tion of a suitable dress. In winter this should consist of one that shall 
cover the body completely. If the child is at all delicate, it ought to wear 
next to the skin a woollen jacket with long sleeves, and covering the chest 
to the neck. Over this should be put a long-sleeved stout muslin dress, or 
one of some light woollen material, made in the same style. In young 
children, the stockings ought to be of wool, and should reach to the knees; 



PROPHYLACTIC TREATMENT. 83 

in older ones, they may be shorter, but the legs should be covered with 
drawers made of canton flannel, of thick cotton stuff, or even of light 
woollen flannel. To show the influence of dress, Dr. Eberle mentions the 
fact that in the country, and especially amongst the Germans, who cover 
the neck and breast, croup is a very rare disease. During a practice of 
six years amongst that class of people, he met with only one case of the 
disease. 

When the liability to the disease continues after the completion of the 
first dentition, I have found the daily use of the cold bath, in connexion 
always with warm clothing, most useful in preventing the attacks. The 
bath must be commenced with in the summer, and persevered in through 
the following winter. The water, after the cold weather begins, should be 
drawn in the evening, allowed to stand all night in a room in which there 
is a fire through the day, and made use of on the following day. Prepared 
in this way, I have fo'und the water in the morning at a temperature of 
between 50° and 60° F. The child ought to be kept in the water only 
half a minute or a minute, then well rubbed, and dressed immediately. 

When the child is pale, weak, and feeble, and unable to bear exposure 
to the outer air, it may generally be restored to much better health, by 
careful attention to diet, and by the steady and long-continued use of some 
tonic remedy. The diet ought to consist of bread and milk, and of meat 
and the simpler vegetables, as potatoes and rice. The tonic most gene- 
rally suitable is quinine, of which a grain may be given in pill or solution, 
twice or three times a day, while at dinner or lunch, or at both, the child 
should be made to drink from a dessert to a tablespoonful of port wine, 
mixed with water. This method ought to be steadily persevered in for 
from three to six weeks or longer. If quinine be objectionable for any 
reason, iron may be substituted. The best preparations are the iodide or 
the metallic iron. 



ARTICLE III. 

PSEUDO-MEMBRANOUS LARYNGITIS, OR MEMBRANOUS 
OR TRUE CROUP. 

Definition ; Synonymes ; Frequency. — Pseudo-membranous laryn- 
gitis is an acute inflammation of the mucous membrane of the larynx, 
attended with exudation of false membrane. 

It is the croup of the French writers, and it is called in this country 
slow, creeping, true, membranous, or inflammatory croup. The term 
given above seems most suitable, as expressive of the real nature and 



84 PSEUDO-MEMBRANOUS LARYNGITIS. 

scat of the disease, and I shall therefore make use of it in contradistinc- 
tion to that of spasmodic laryngitis or spasmodic or false croup, which is 
a much more common and less dangerous form of disease. 

The frequency of the disease is very considerable. During the five 
years from 1844 to 1848 inclusive, there occurred in this city 3376 
deaths, under fifteen years of age, from bronchitis, croup, pneumonia, 
hooping-cough, consumption, and other diseases of the respiratory organs. 
Of this number, 756 were from croup alone ; and as spasmodic croup is 
seldom a fatal disease, it is reasonable to conclude that much the larger 
number of deaths returned as from croup, were, in fact, caused by the 
disease now under consideration. It is rare, however, in comparison with 
spasmodic laryngitis. During the last nine years I have met with sixteen 
cases of pseudo-membranous laryngitis, or true croup, in which the disease 
either attacked the larynx primarily, or followed pseudo-membranous 
angina. During the same period of time, I have seen eighty-nine cases 
of spasmodic laryngitis, or croup, of which I have kept a faithM record, 
and a considerable number of cases besides, of which I have no written 
account. 

Predisposing causes. — Age. — The disease is most frequent between 
the ages of two and seven years. Of the sixteen cases that I have seen, 
thirteen occurred between two and seven years of age, and the other 
three at the ages of eighteen months, nineteen months, and eleven years 
respectively. As to sex, it is said to be more frequent in boys than girls. 
A feeble and delicate constitution is thought by some to be a powerful 
predisposing cause, but this is at the least, very doubtful. Of the 
fifteen cases referred to, all but two occurred in healthy, vigorous 
children, and these two were neither very weak nor very sickly, but pre- 
sented a rather more delicate appearance than usual. Season appears 
to exert some influence as a cause, since the disease is apt to be most 
prevalent in spring and autumn. It is either sporadic or epidemic, re- 
sembling in this respect pseudo-membranous angina. When epidemic it 
is very generally connected with angina, while the sporadic cases fre- 
quently begin in the larynx, and often run their course without impli- 
cating the pharynx. During the latter part of the year 1844, the* whole 
of 1845, and a part of 1846, the disease prevailed extensively in this 
city, and was in many cases accompanied by the pharyngeal affection. 
During those years, and particularly in 1845, measles and scarlatina also 
prevailed to a great extent, especially the former. 

Is the disease contagious? In the article on pseudo-membranous 
angina, it will be stated that some of the most distinguished authorities 
unhesitatingly pronounce that disease contagious. In regard to the one 
under consideration, more doubt is expressed, and both M. Valleix, and 



CAUSES — ANATOMICAL LESIONS. S5 

Rilliet and Barthez, say that additional facts are necessary to determine 
this point. My own experience has never given me any reason to sup- 
pose that it is propagated by contagion, except when connected with 
pseudo-membranous angina, as I have known it extend from one child to 
others in the same family only in that class of cases. 

The exciting causes are but little understood. The only ones which 
seem to have been ascertained with any certainty, are the application of 
irritating agents to the laryngeal mucous membrane, and exposure to 
cold; and even these are questioned by the most accurate observers. In 
none of the cases that I have seen, could the exciting cause be even 
suspected. 

Anatomical Lesions. — The false membrane may cover the whole 
mucous membrane of the larynx, and extend into the pharynx, trachea, 
and even bronchia ; or it may be confined to the larynx, either forming 
a complete lining for the cavity of that organ, or consisting merely of 
patches of various sizes, with intervals of mucous membrane between, 
destitute of exudation. 

It is important to ascertain the proportion of cases in which the 
deposit extends into the bronchia, and those in which it remains limited 
to the larynx, or larynx and trachea, as the determination of this point has 
a strong bearing upon the question of the propriety of the operation of 
tracheotomy. It appears from a table given by M. G-uersent {Diet, de 
Medicine, t. ix. p. 346), containing the results of cases collected by M. 
Hussenot, from various sources, and of autopsies made by M. Bretonneau, 
numbering in all one hundred and seventy-one, that in seventy-eight the 
membrane did not extend beyond the trachea, and that in forty-two, it 
invaded the bronchia : in thirty, the condition of the bronchia was not 
mentioned ; and in twenty-one, there were no false membranes ; — so that 
of one hundred and twenty cases, in which the extent of the false mem- 
brane was accurately noted, it was confined to the larynx and trachea in 
seventy-eight, and extended into the bronchia only in forty-two. In 
about two-thirds of the cases, therefore, the exudation was confined to the 
larynx and trachea, which agrees exactly with my own experience in this 
city, since of six cases, in which I ascertained with exactitude (four by 
autopsy, and two by tracheotomy) the extent of the deposit, it passed 
into the bronchia only in two. 

The proportion of cases in which the pharynx is implicated is also 
important, since it affects the diagnosis of the disease. Dr. West reports 
eleven cases of idiopathic croup, in only two of which there was any for- 
mation of false membrane upon the velum and tonsils. Of fourteen cases 
observed by myself, in which the condition of the throat was recorded, 
the croup followed membranous angina in six; in five, the disease began 



SO PSEUDO-MEMBRANOUS LARYNGITIS. 

in the larynx, but was attended at a later period with small deposits upon 
the tonsils ; and in three there was no deposit on the throat at any time. 

The false membrane is commonly of a yellowish-white color, and 
from a fifth of a line to a line in thickness. Its consistence is generally 
considerable, and it is usually somewhat elastic. The free surface is usually 
covered with puriform mucus, while the inner surface is adherent with 
various degrees of force to the mucous membrane beneath. It consists, 
according to Hasse, mainly of fibrin blended with mucus in various pro- 
portions. (JPatholog. Anat. Sydcn. Soc. Edition, p. 278.) 

The mucous membrane presents various shades of redness, or it is pur- 
plish, or even blackish. In other cases it retains its normal characters, 
a circumstance which has given rise to the opinion entertained by some 
persons, that the disease is not inflammatory, though it is altogether 
probable that this condition is consecutive to the formation of the exuda- 
tion. The membrane is sometimes brittle, friable and thickened, and in 
rare instances softened. 

Bronchitis and pneumonia are frequent complications of the disease ; 
the other organs are healthy in the great majority of cases, with the 
exception of venous congestion. 

In the secondary croup of measles the appearances are very similar to 
those observed in primary cases, while in that of scarlet fever the exuda- 
tion differs in being less consistent and less uniformly spread over the dis- 
eased part. In the last-named malady the membrane is thinner, less adhe- 
rent, and softer, and in some cases puriform, soft, and of a grayish color. 
It is usually poor in fibrin and prone to decomposition. The mucous 
membrane is generally discolored and softened. 

Symptoms. — It is highly important to ascertain in what proportion of 
cases the disease begins in the larynx, and in what in the pharynx. It 
is difficult, however, to determine this question in the present state of 
knowledge upon the subject, as it has not been carefully examined by a 
sufficient number of observers. Rilliet and Barthez state that a majority 
of the cases observed by themselves, and also of those of M. Hache, com- 
menced in the larynx. M. Guersent, on the contrary (Diet, de Med., t. 
ix. p. 339), asserts that in nineteen-twentieths of the cases, it begins in 
the pharynx, and I have heard some physicians in this city assert that the 
diagnosis between this disease and common or spasmodic croup, cannot be 
considered as positive during life, unless the pharynx contains an appre- 
ciable amount of pseudo-membranous exudation. From this I entirely 
differ, and believe, on the contrary, that the disease often attacks the 
larynx without at all implicating the pharynx, while, in a considerable 
number of cases, the pharyngeal complication is exceedingly slight. Of 
the sixteen cases that I have seen, the disease followed membranous 






SYMPTOMS. 87 

angina in six ; it began in the larynx, but was accompanied in the after 
part of the case with exudation upon the fauces, in five ; in three there 
was no deposit in the fauces at any period of the disease ; and lastly, in 
two, the state of the throat was not recorded. The membrane was present 
in the fauces in only two out of eleven cases of idiopathic croup mentioned 
by Dr. West ; so that it is very evident that the presence of exudation 
upon the tonsils is not at all necessary to make the diagnosis of the 
disease positive. It is probable that the disease is most apt to begin in 
the pharynx in epidemic cases, while in those which are sporadic, it most 
frequently begins in the larynx. 

When the disease begins in the pharynx the early symptoms are the 
same as those of pseudo-membranous angina. After a longer or shorter 
period, from one to seven days usually, according to the nature of the 
epidemic, the malady extends into the larynx, causing cough and hoarse- 
ness, and then follows the same course as when it commences in that 
organ. When, on the contrary, it begins in the larynx, the invasion is 
marked by hoarseness of the voice, and hoarse, croupal cough, which often 
continue for one, two, or three days, until the disease has made conside- 
rable progress, before the parents deem it necessary to send for a physician. 
In one case that came under my observation, the child was playing about 
the room at a time when he had hoarse, whispering voice and cough, and 
stridulous respiration. In another I was not called until the evening of 
the third day, though the child had had stridulous cough and respiration 
for two nights, but, as he always seemed better in the morning, it was not 
thought necessary to send for me until after he had become violently ill. 
In a third there was hoarseness of the voice and slight croupal cough 
during the afternoon of one day and the ensuing night, and the next 
morning fully developed croup, with fibrinous patches on each tonsil. 

These symptoms are not generally accompanied by fever at first. The 
appetite is usually unimpaired, the thirst scarcely augmented, and the 
child, though somewhat dull and languid, is disposed to be amused at 
times. In other and severer cases, on the contrary, the disease becomes 
aggravated much more rapidly, and may soon lead to a fatal termination. 

The change of the voice is the first symptom observed in the cases 
which begin in the larynx. It was always described to me as hoarse, like 
that which is heard in an ordinary cold. As the disease progresses, the 
voice becomes more and more hoarse and difficult, until at length it is 
reduced to a mere whisper. The degree of the hoarseness varies however 
to a very great degree in the same case, the diversities depending pro- 
bably upon the amount of the spasm of the larynx at the moment, and 
upon the state of the exudation. I have several times observed the voice 
to become much stronger and clearer after the operation of an emetic, in 



88 PSEUDO-MEMBRANOUS LARYNGITIS. 

consequence no doubt of its relaxing effect upon the glottis. The cough 
is peculiar. At first slightly hoarse, it becomes, as the case goes on, very 
hoarse and hollow, and then short and smothered. It is variable in fre- 
quency, and is apt to occur in paroxysms, which are often very trouble- 
some from their frequent recurrence. Towards the termination of the 
disease in fatal cases, or whenever the case is very severe, it is altogether 
different in character from what it was at the beginning, becoming short, 
instantaneous, and smothered, so that it might very well be called whis- 
pering. As the disease progresses, it is accompanied by stridulous 
respiration, in which a hoarse, rough, hissing, or crowing sound is pro- 
duced by the rush of the air through the constricted larynx. This sound 
is usually heard at first only during forced inspirations, and is therefore 
noticed first during the long inspiration which precedes coughing. Next 
it is heard during the violent respiratory movements which accompany 
the act of crying; and as the larynx becomes more and more clogged with 
the exudation, it occurs during both inspiration and expiration, in every 
respiration, and is so loud as to be heard over the whole room, or even in 
adjoining rooms. 

The respiration is natural in the early part of the attack, but as the voice 
and cough assume their characteristic features, and the stridulous sound is 
established, it becomes more frequent, rising to 28, 32, 40, and 48, in the 
minute. At first easy and natural, it becomes, during the height of the 
symptoms, and especially in fatal cases, the most frightful dyspnoea I have 
seen in any disease. Every movement of inspiration requires the whole force 
of the inspiratory muscles to lift the walls of the chest, and enable the air to 
find its way through the narrow and obstructed glottis; each expiration, in- 
stead of being short and easy, as in health, and in nearly all other diseased 
conditions, requires a slow and laborious contraction of the expiratory 
muscles to expel from the lungs the air which they contain, and which hisses 
through the larynx with a sound nearly as loud as that produced during 
inspiration. The dyspnoea just described occurs sometimes in paroxysms, 
but is for the most part constant. In only one of my cases did it assume 
the form of paroxysms, and in that the patient recovered. In the others, 
both favorable and unfavorable, it was constant, or at least the variations 
were slight, and dependent chiefly upon the action of emetics. 

When the dyspnoea occurs in paroxysms, the expression of the child is 
that of the most terrible anxiety, or of the wildest terror. In one instance, 
the face became deeply red, then blue, livid, and finally pale and white, 
and for a moment life seemed extinct. In the other cases, in which the 
dyspnoea was constant, the face was of a dusky red color, the expression 
anxious and haggard, and the child either laid on its side with the head 



SYMPTOMS. 89 

thrown far backwards in a state of somnolence or was constantly changing 
its position, from restlessness, without noticing anything around it. 

There is no expectoration early in the disease, or it consists of white or 
yellowish viscous mucous. At a later period, there is often expectoration 
of false membrane, sometimes in the form of a complete tube, or much 
more frequently, of small irregular fragments, mixed with mucus, or with 
the matters ejected from the stomach by vomiting. To detect the mem- 
brane, the substances expectorated or vomited ought to be placed in water, 
when it detaches itself from the mucus and other matters, and is easily 
recognised. It is not voided in all the cases in which it is known to be 
present in the larynx. Thus, of the sixteen cases observed by myself, it 
was expelled by vomiting or coughing in five; in nine, none was rejected, 
though its presence in the case was proved by the character of the symp- 
toms and by its existence in the fauces, by autopsy, or by the operation 
of tracheotomy • in one there was expectoration of masses of viscid, yel- 
lowish fibrin, though none of membrane ) and in one there was no positive 
evidence of its existence. M. Valleix ( Guide du Med. Prat., tome i., p. 
830) states that of fifty-one cases, in which the symptoms were very care- 
fully observed, no traces of the exudation could be discovered either in 
the expectoration or in the matters rejected by vomiting in twenty-six, 
though its existence was proved by post-mortem examination. 

Auscultation. — In the severe cases of true croup that have come 
under my notice, auscultation has been of little or no aid to me. In fact, 
the chest sounds have been, in all such cases, so completely masked 
by the loud shrillness of the laryngeal stridor, that I have been un- 
able to judge with any satisfaction to myself of the condition of the 
lungs. It has been impossible to determine whether the inability to 
detect natural respiratory murmur depended on the small volume of air 
that found its way through the obstructed larynx, or on the fact that all 
sound was masked by the stridor. This is particularly unfortunate, since, 
were it not for this circumstance, we might be able to judge by ausculta- 
tion of the extent to which the bronchia may have been invaded by the 
false membrane, a matter very important to determine, when the question 
of tracheotomy comes to be mooted in a case. 

In cases in which the laryngeal obstruction is not very great, and the 
stridulous sound consequently less loud, we may auscult the chest to some 
profit. The vesicular murmur is then either natural, or altered according 
to the state of the lung. 

But, though such has been my own experience in regard to auscultation 
in croup, MM. Barth and Koger (Trait. Prat, d' Auscultation, 2d ed. 7 
p. 255 and 261) describe, as a sign of croup with floating false membrane, 
a kind of vibrating murmur, or tremblotement, as though a movable mem- 



90 



PSEUDO-MEMBRANOUS LARYNGITIS. 



branous veil were agitated by the respired air, and which can be heard when 
the stethoscope is applied over the larynx or trachea. If this sound be 
beard only in the larynx, and not in the trachea and bronchia, it indicates 
that the plastic exudation is of small extent, and likely to be rejected 
by expectoration, and the prognosis is favorable. In the other case, 
on the contrary, it shows the disease to be of considerable extent, and the 
prognosis becomes much more serious. 

There is a slight febrile movement at the onset, or a day or two after 
the appearance of the earliest symptoms. When the disease is fully esta- 
blished, the fever becomes violent, and the pulse rises to 130, 140, 160, 
or even higher. It is generally regular and strong at first, but as the case 
progresses, becomes small, feeble, and very rapid. In one of the parox- 
ysms that I witnessed, it became so rapid that it could not be counted, 
and at last ceased to beat at either wrist for a few instants. The 
heat and dryness of the skin are very moderate at first, but increase as 
the disease reaches its maximum, to diminish afterwards gradually, and 
in fatal cases, to be replaced by coldness, with copious clammy perspira- 
tions. The strength is not diminished at first, but as the disease progresses, 
becomes so more or less in proportion to the violence and duration of the 
case. The digestive organs are but little disturbed by the influence of 
the disease, with the exception of diminution or loss of appetite, and 
moderate thirst, during the violent period. Spontaneous vomiting or 
diarrhoea are rare, though both sometimes occur. The tongue is moist, 
and generally covered with yellowish-white fur. Pain in front of the 
larynx has been noticed by several authors. I have never observed it. 

Tumefaction of the submaxillary glands, which is a frequent symptom 
of pseudo-membranous angina, ought always to be sought for, and when 
present, lends additional support to the diagnosis. 

The mode of recovery in favorable cases is different in different in- 
stances. In some it is sudden, taking place rapidly and steadily after the 
expectoration of a tubular-shaped membrane. The rejection of the deposit 
in this form, is, however, a rare event, and is not always followed by 
recovery. I have seen in this city three distinct tubules of false membrane, 
which were thrown from the larynx of the same child at intervals of two 
days each. The first was the largest, and came evidently from the whole 
length of the larynx and trachea ) the second was somewhat shorter, and 
the third not more than half so long as the first. The child was greatly 
relieved for some hours on each occasion of the rejection of a tubule, but 
then became more oppressed as the exudation again collected. It sank 
from exhaustion after the third came away. 

As a general rule, the recovery is slow and gradual. After free vomit- 
ing, after the expectoration of fragments of false membrane mixed with 



DURATION — DIAGNOSIS — PROGNOSIS. 91 

mucus, or, as happened to myself in two cases, after the expectoration of 
masses of tough yellowish fibrine, or, lastly, after the rejection of mucoid 
and frothy sputa only, the symptoms gradually ameliorate ; the stridulous 
respiration slowly subsides, and at last disappears ; the cough, which was 
short, hoarse, and smothered, became louder, stronger, less hoarse, and, 
what is still more favorable, loose; the aphonia moderates, but very 
slowly; the fever disappears; appetite and gaiety return; and after a 
variable length of time, the child enters into full convalescence. The 
hoarseness of voice very generally continues for several days after all the 
other symptoms have lost their dangerous character, and sometimes lasts 
for weeks. In one case, the voice was still weak and hoarse on the tenth 
day, and in another during the seventh week. (See a paper on croup, oy 
the author, Am. Jour. Med. Set., April, 1847.) 

Duration. — Death has been known to occur on the first, second and 
third days, but such cases are rare. The duration of the disease may be 
stated at from three to thirteen days, a3 its most common term. The 
cases seen by myself, lasted from five to fourteen days. 

Diagnosis. — The diagnosis of true croup presents no difficulties, when 
it follows pseudo-membranous angina. But when, on the contrary, the 
disease begins in the larynx, and especially when there is no exudation 
whatever in the fauces, the diagnosis becomes more embarrassing, since, 
under these circumstances there are two other laryngeal affections with 
which true croup may be confounded, — to wit, false croup or spasmodic 
laryngitis, and laryngismus stridulus. The mode of distinguishing be- 
tween the different disorders, will be carefully described in the remarks 
on diagnosis, under the head of the two last-named diseases. I wish in 
this place merely to call the attention of the reader, and particularly of 
the young practitioner, to the extreme importance of the differential diag- 
nosis between the disease now under consideration, and false or spasmodic 
croup, since the former is one of the most dangerous and frightful disor- 
ders to which children are subject, demanding vigorous and active treat- 
ment from the start, at which period only, is medical treatment likely to be 
successful ; whilst the latter, though of a much more threatening aspect at 
the beginning, is in fact a mild and safe disease in comparison, and one 
rarely requiring other than very simple treatment. 

Prognosis. — Pseudo-membranous laryngitis is a very fatal disease. 
It is particularly fatal in cases which occur during seasons of epidemic 
prevalence of the disease, as under these circumstances, it very generally 
follows membranous angina, itself a severe and dangerous disorder. 
When the disease occurs in a sporadic form, it is somewhat less dangerous, 
though it ought at all times, and in all shapes, to arouse the utmost 
caution of the practitioner. Rilliet and Barthez state that its common 



92 PSEUDO-MEMBRANOUS LARYNGITIS. 

termination is in death. M. Valleix says that " to speak in general terms, 
it is fatal when not treated energetically." Guersent (Loc. tit. p. 365), 
after a careful consideration of the statements of different authors, says; 
" In fact, true croup is one of the most dangerous of all diseases, and is 
generally fatal." He adds that he has seen at least a hundred cases of 
spasmodic croup, without a single death, while of ten children attacked 
with true croup, it is scarcely possible to save two. The degree of mor- 
tality is very strikingly different in different epidemics. Thus of sixty 
cases observed by M. Ferrand in the villages about La Chapelle-Veronge, 
not a single one escaped (Diet, de Med. t. ix. p. 364, 399). Other 
writers speak of having cured three or four in forty, and others nearly all. 
Dr. Bard, of New York, says that of sixteen cases, seven died. Of the 
sixteen cases that I have seen eight died. Of the sixteen, six followed 
violent pseudo-membranous angina, of which four died. The remaining 
ten began in the larynx, and of these, four died, and six recovered. It is 
clear, therefore, that the disease is less dangerous when it begins in the 
larynx, than when it follows in the course of membranous angina. 

The danger is great in proportion as the child is younger and more 
feeble, and in proportion to the rapidity of the case and the degree of the 
dyspnoea. The most unfavorable symptoms are : loud stridulous sound 
heard both in the inspiration and expiration ; laborious and prolonged 
expiration; whispering voice or complete aphonia; congestion of the face 
and neck ; somnolence ; weak, rapid, and irregular pulse ; cold extremi- 
ties ; and cold clammy perspirations. The favorable symptoms are : 
expectoration of false membrane ; diminution of the stridulous respiration ; 
the change from whispering to hoarseness or to clearness of the voice; 
looseness of the cough; moderation of the fever; improvement of the 
temper and moral state ; and amelioration of the general condition. 

The case should not be abandoned as hopeless until life is actually ex- 
tinct. I myself saw a child recover after momentary suspension of ani- 
mation, by asphyxia, on two occasions, though these attacks were followed 
by a dreadful illness of two days. (See paper by the author. Loc. cit.*) 

Treatment. — I am desirous, at the beginning of my remarks upon the 
treatment of this disease, to express the opinion, that none is likely to 
succeed, unless it be applied early in the case, and by this I mean, in the 
course of the first, or at the latest, second day. And not only should 
it be commenced early, but the most powerful remedies ought to be 
applied at this period, in their full force. The very moment there 
is good reason to suppose that a case will prove to be one of membranous 
croup, the most energetic means ought to be brought to bear upon it, and 
if this be done from the first, or even second day, I cannot but hope that 
a considerably larger proportion of recoveries may take place, than has 



TREATMENT. 93 

heretofore been thought possible. Of eight cases treated in the manner 
I shall recommend, from a very early period of the attack, six recovered, 
though one of the recoveries, let it be observed, was obtained only by the 
operation of tracheotomy, so that but five of the eight are to be ascribed 
to the medical means employed. Of eight cases not treated in the mode 
referred to, only two recovered, and in one of these, the patient was res- 
cued from death by tracheotomy. Of the latter cases, I saw three in con- 
sultation, late in the attacks, two on the third day when the disease had 
already made most disastrous progress, one on the tenth day, when the 
mouth was already bluish from venous congestion, and the other two 
several years since, before I fully understood the importance of early and 
energetic treatment. 

In the study of the treatment, it will be necessary to rely chiefly upon 
the works that have been published since the distinction between the two 
forms of croup has been correctly drawn, for it is impossible to place much 
dependence on the assertions of previous writers, inasmuch as their opi- 
nions in regard to the effects of treatment must have been formed from 
indiscriminate experience in two very opposite maladies. It is only neces- 
sary to recollect the enormous difference in the mortality of the two affec- 
tions, to be convinced that the success of any plan of treatment in the one, 
is no fair argument for its probable success in the other. Thus M. G-uer- 
sent has seen a hundred cases of spasmodic laryngitis, without a single 
death ; while he believes that of ten cases of pseudo-membranous disease, 
scarcely two can be saved. I have myself attended, and kept a record of 
eighty-nine cases of spasmodic croup, and have seen a considerable number 
of cases besides, of which I have no notes, without a single death; whilst 
of seventeen cases of true croup that I have met with, eight proved fatal. 
The most important objects to be held in view in the treatment, are the 
following : to prevent, if this be at all possible, the formation of false 
membrane ; after its production, to cause its dissolution, or render it less 
adherent ; to provoke its expectoration ; to prevent its reproduction after 
it is once expelled ; to subdue the inflammatory diathesis which exists ; 
and to allay the painful symptoms. l 

Bloodletting. — Many authors award to bloodletting the first place in 
importance amongst the remedial means in our possession, and it seems to 
be regarded by many in this country as an indispensable agent in the cure. 
Moreover, there are not a few who believe that, when promptly and boldly 
resorted to, it will seldom fail in arresting the disease. Underwood says 
(Bell's Ed., p. 273) : " Bleeding is always necessary, if the physician be 
called at the commencement of the disease, or stridulous noise ; and if the 
patient be visited too late to endure this evacuation, I believe no hope can 
remain of his being benefitted without it, unless the infant be very young ; 



94 PSEUDO- MEMBRANOUS LARYNGITIS. 

which, however, in another view, cannot but add to the danger/' Dewees 
recommends it very highly in fully developed cases attended with fever, 
and advises that it be repeated if the symptoms persist. Eberle says 
(Dis. of Child., p. 356): "Without doubt, however, the remedy upon 
which our principal reliance should be placed, for the removal of the tracheal 
inflammation is bloodletting." Dr. Condie (Dis. of Child. 2d edit. p. 305) 
recommends it as the most effectual remedy in arresting the disease, and 
says that " the practitioner, who in violent cases, neglects this important 
measure, and places his^hopes on any other remedy, or combination of reme- 
dies, will have but little reason to flatter himself upon his success in the 
management of the disease." Unfortunately for us, the value of the opi- 
nions just quoted is very much diminished by the fact that the authors 
who emit them, have not clearly distinguished between the two varieties 
of the disease, so that their experience is derived in part at least from the 
effects of the remedy in spasmodic croup ; and, as it is now well known 
that that disease is very readily cured in the vast majority of cases, it is 
easy to understand the confidence they express in the utility of any means 
they may have employed. 

But if we examine the works of those who have made the distinction 
between the two diseases, we shall find different opinions from the above 
expressed in regard to the efficacy of bloodletting. 

Guersent (Loc. cit., p. 373) asserts that bleeding has not the power of 
arresting the progress of this specific inflammation, — that the disease 
continues with greater or less rapidity under the influence of general and 
local bleedings, and almost always terminates fatally, though the detrac- 
tions of blood may have been pushed to the utmost limit. Bretonneau is 
of opinion that it has no effect in preventing the formation of the false 
membrane. Valleix (Loc. cit, p. 353) says: "From the examination of 
a large number of cases, I am convinced, with M. Bretonneau, that bleed- 
ing, whether general or local, is not a powerful curative means, and that 
it does not obviously arrest the progress of the disease." Billiet and 
Barthez (T. i., p. 252) are of opinion that bloodletting ought to be re- 
sorted to only in vigorous children, in the early part of the attack in 
sporadic cases, and in those in which the febrile reaction is violent, and 
the suffocative symptoms strongly marked ; while it should be abstained 
from in epidemic and adynamic cases, in young, pale, and lymphatic chil- 
dren, when the fever is slight and the dyspnoea moderate, and lastly, that 
it ought never to be employed in the advanced stage of the disease. Dr. 
Wood (Treatise on the Prac. of Med. , vol. i., p. 788), in his remarks on 
the treatment of the disease, says : " Depletion, in this variety of croup, 
is much less efficient than in the catarrhal." He adds that the utmost to 



TREATMENT. 95 

be expected from it is, that it may moderate the severity of the inflam- 
mation, and thus probably diminish the amount of the effusion. 

I proceed now to state the results of my own experience as to its effects. 
It was employed in two of the six cases which began as angina: in one the 
child was bled once and leeched once, and recovered ; in the other, leeches 
were used and the case terminated fatally ; in neither of them could I per- 
ceive that the depletion exerted any positive control over the symptoms of 
the disease. In the four remaining cases no bloodletting was employed, and 
of these three proved fatal. In ten cases the disease began in the larynx, 
and depletion was used in all of these. The ages of the subjects were as 
follows : one, eighteen months; two, two years; four, three years; two, 
between four and five years; and one, six. Eight of the ten were bled 
from the arm, and two leeched on the neck. In two of those bled, leeches 
were also applied to the neck. A single venesection of four ounces was 
employed in seven, while in two, a venesection of about the same amount 
was performed three times in each. Of the ten cases, six recovered and 
four died, but in one of the favorable cases no credit is due to the 
depletion, since the child was saved only by the operation of tracheotomy. 
The two cases bled to the largest amount (three times each) recovered. 
In one of these there were small patches of fibrin e on each tonsil, and 
rejection of false membrane by coughing and vomiting. 

The immediate effect of bleeding was decidedly more beneficial in the 
second series of cases than in those following angina ; it caused diminu- 
tion of the fever and dyspnoea. In none, however, was the relief from 
bleeding so great as that which followed the full operation of an emetic, 
and be it remarked, that emetics were freely employed in all. 

Emetics. — Emetics are recommended by all writers, and are generally 
acknowledged to be amongst the most, if not the most, efficient, of all the 
means employed. M. Valleix (Loc. cit., t. i. p. 358) has demonstrated 
their importance more fully than any other writer. He states that of 
fifty-three cases of the disease, tartar emetic and ipecacuanha were chiefly 
relied on in thirty-one, of which fifteen were cured ; whilst of the twenty- 
two others in which they were parsimoniously given, not a single one 
recovered. He gives other facts in regard to these cases which are 
highly interesting and important. Thus of the thirty-one cases treated 
with powerful emetics, false membrane was rejected during the efforts of 
vomiting in twenty-six, and of these fifteen, or nearly three-fifths recovered. 
In the five others of the thirty-one, on the contrary, no membrane was 
expelled, and they all terminated fatally. Again, of the twenty-two cases 
in which emetics formed but a secondary part of the treatment, two 
rejected false membrane, and of these one recovered; while of the twenty 
others in which no false membrane was expelled, not one escaped. 



06 PSEUDO-MEMBRANOUS LARYNGITIS. 

Of the cases that occurred in my own practice, emetics were freely ad- 
ministered in two of the six which began as angina; in three they were used 
to a slight extent ; and in the sixth not at all. The first two recovered, but 
as in one of these tracheotomy was performed, it is impossible to ascribe 
the cure to the emetics. The other four cases died. In only one was 
there any rejection of false membrane, and this was in very small quan- 
tity, and occurred in the child who was ultimately saved by the operation. 
They were used energetically, and frequently repeated, in eight of the ten 
cases, beginning as laryngitis. Of the eight, five recovered. In four of 
the eight cases, fragments of false membrane were rejected, and in a 
fifth, a mass of viscid, yellowish fibrine (this case was marked as one of 
unquestionable membranous croup, by patches of false membrane on the 
tonsils). Of these five, four recovered. In three of the eight, no false 
membrane was rejected, and of these two died. In two of the ten cases, 
they were not freely used, being employed in one only as a secondary 
means, and in the other only at the very termination of the attack, as I 
was not called to the case until the tenth day, the patient having been 
under homoeopathic treatment before. The first of these two cases proved 
fatal, and the second was rescued from impending death only by the 
operation of tracheotomy. 

It seems to me that these facts are sufficient to show that emetics exert 
a most powerful and beneficial influence on the disease, and that they 
ought, therefore, to enter into the treatment as principal remedies. 

The emetics generally employed in Europe and this country are tartar 
emetic and ipecacuanha, which are given in the usual doses to produce 
full vomiting. I have been in the habit of employing a substance as an 
emetic, which, so far as I know, was first recommended for that purpose 
by my father. The substance to which I refer is the alumen of the 
pharmacopoeia. In an article published by my father in the Med. Exa- 
miner (vol. i., p. 414, 1838), he says he has been " accustomed to make 
use of an emetic, which, so far as I can learn, is very little employed, but 
which, from the certainty and the speediness of its operation, ought to be 
more generally admitted into the list of available medicines for this par- 
ticular case at least. I have been familiar with its effects for more than 
twenty years, and my confidence in them increases rather than diminishes 
by time." He adds, " I think that I have never given more than two 
doses without causing very full vomiting; but I have often large quanti- 
ties of antimonial wine and ipecacuanha, without succeeding in exciting 
the efforts of the stomach." 

The alum is given in powder, in the dose of a teaspoonful, mixed in 
honey or syrup, to be repeated every ten or fifteen minutes, until it 
operates. It is very seldom necessary to give a second dose, as one 



TREATMENT. 97 

operates in the majority of eases very soon after being taken. I have 
known it to fail to produce vomiting only in two instances, both of which 
were fatal cases. In one the disease had gone so far before I was called, 
that no remedy had any effect upon the stomach. Iq the other, it was 
administered several times with full success, but lost its effect at last, as 
had happened also in regard to antimony and ipecacuanha. The reasons 
for which I prefer alum to antimony, or ipecacuanha, are the following : 
antimony, when resorted to as frequently in the disease as I am of opinion 
that emetics ought to be, is too violent in its action ; it prostrates many 
children to a dangerous degree, and is, I fear, in some cases, itself one 
cause of death. It acts injuriously upon the gastro-intestinal mucous 
membrane, when used in large quantities, and for any length of time. 
Again, it is very apt to lose its effect, and to fail to produce sickness. 
Ipecacuanha is a much safer remedy than tartar emetic, but its operation 
is often too mild, and it also ceases to produce any effect after it has been 
used several times. The advantages of the alum are that it is certain 
and rapid in its action, and that it operates without producing exhaustion 
or prostration beyond that which always follows the mere act of vomiting. 
It does not tend like antimony, and in a less degree ipecacuanha, to pro- 
duce adynamia of the nervous system ; an effect which, in some constitu- 
tions or states of the constitution, or when it has been exhibited frequently, 
is often attended with injurious or even dangerous consequences. I have 
given alum in the dose above mentioned, twice and three times a day, for 
two and three days, without observing any bad effects to result from it. 
The alum was given in all the cases that I have seen, in which emetics 
were used, and was the only one employed when it was found to produce 
full vomiting, with the exception of ore of the cases accompanied by 
violent angina, in which ipecacuanha was substituted because of its 
smaller bulk. I have already said that it failed to produce vomiting only 
in two instances. It was the emetic employed in the four cases in which 
fragments of false membrane were rejected, and in that in which the yellow 
viscid fibrine was expelled. Although it did not occasion the rejection of 
membrane in the other cases, it operated most speedily and efficiently. 

Sulphate of copper has been highly recommended by several writers for 
its emetic operation, and by some German physicians, as exerting a spe- 
cific influence upon the disease in addition to its emetic effect. As an 
emetic it may be given to a child two or three years old, in the dose of 
from half a grain to a grain every fifteen minutes, until it operates. To 
obtain its specific action it is continued afterwards in doses of a quarter of 
a grain every two hours. 

There is another remedy which has been proposed as an emetic by Dr. 
Hubbard, of Hallowell, Maine. This is the turpeth mineral, the subsul- 



98 PSEUDO-MEMBRANOUS LARYNGITIS. 

pliatc or yellow sulphate of mercury, the hydrarg. sulphas flavus of the 
American pharmacopoeia. Dr. Hubbard recommends it on the grounds of 
promptness and certainty, of its never producing catharsis, and lastly of its 
not being followed by prostration like that occasioned by tartar emetic. 
The dose is two or three grains for a child two years old, to be repeated 
every ten or fifteen minutes, until it operates. He says that if the first 
dose fails, the second usually acts as soon as it reaches the stomach. I 
have made trial of this remedy in two cases. The first was one in which 
alum and tartar emetic had lost their power from frequent repetition. 
The dyspnoea was intense, and as I believed that the only chance of 
escape for the child was the operation of an emetic, I proposed the sub- 
sulphate. The age of the child was three years. Three grains diffused in 
syrup were administered. It operated powerfully within a few minutes, 
and when I saw the patient one hour after, the distressing symptoms were 
considerably ameliorated. The improvement did not last, however; the 
child died in a state of exhaustion very soon after. The other case was 
that of a boy nine years of age, in whom the alum had operated fully, but 
as it failed to dislodge the membrane, and his situation was desperate if 
not relieved, I made trial of the turpeth mineral. Six grains were given 
in two doses, at fifteen minutes interval, but they produced no effect what- 
ever. The case terminated fatally, and the whole larynx and trachea 
were found filled with a thick membrane. 

I conclude these protracted remarks upon emetics with the statement, 
that from what I have read and from personal experience, I am induced 
to regard them as the most important remedies we have to oppose to this 
fearful malady. The emetic, whichever it may be, ought to be given at 
least twice, generally three or four times, and sometimes oftener, in the 
twenty-four hours ; the period and frequency of the administration to be 
determined by the stage and urgency of the symptoms, and by the consti- 
tution and present strength of the patient. 

Calomel. — Dr. Samuel Bard states that Dr. Douglas of Boston, who 
published in the year 1736 an account of the angina suffocativa, was the 
first to recommend the employment of mercury in the disease. Bard says 
that he was induced to try mercurials after reading Dr. Douglas's little 
essay, and adds, " the more freely I have used them, the better effects I 
have seen from them." He gave calomel in the quantity of thirty or 
forty grains in five or six days, to children three or four years old ; " not 
only without any ill effects, but to the manifest advantage of my patient ; 
relieving the difiiculty of breathing, and promoting the casting off the 
slough beyond any other medicine." He recommends that the first one or 
two doses be combined with an opiate. He considers mercury as the 
basis of the cure. 



TREATMENT. 99 

Since it has been so highly recommended by American practitioners, 
mercury has been extensively employed and relied on by European physi- 
cians. Bretonneau gave it in large doses, and Rilliet and Barthez re- 
commend it in the same way. Valleix, on the contrary, doubts whether 
there are any cases of true croup on record, cured by calomel alone. 

Calomel was freely given in nine of the sixteen cases treated by 
myself. Of the nine cases, six recovered, and three died. Of the seven 
cases in which it was not so used, five died. It ought to be observed, 
however, that one of the six recoveries under the free use of calomel was 
obtained by tracheotomy, though even here the beneficial effects of calomel 
were most manifestly obvious, since this was the only one of three cases that 
occurred in the same family, in which the exudation remained limited to 
the larynx and trachea ; whilst in the other two in which calomel was not 
abundantly employed, the deposit extended deeply into the bronchia, and 
caused a fatal termination. It was doubtless the limited extent of the mem- 
brane, moreover, that allowed the operation to succeed, whilst this failed, as 
might have been expected, could the extent of the deposit have been known 
beforehand, in one of the two other cases last mentioned in which it was 
performed. I wish to state, also, that one of the two favorable cases of the 
series in which calomel was not largely employed, was clearly an instance 
of rescue by tracheotomy, since the patient was rapidly approaching death 
when the operation was performed. 

The most important point in regard to the use of mercury in slow croup, 
and indeed of bloodletting and emetics also, is that the treatment should 
be commenced at an early period. It ought to be given early, in order to 
produce upon the blood its defibrinizing effect, and thus prevent, or at 
least limit, the extension of the deposit. When begun with after the 
second or third day, it is very questionable whether it will be of much 
service, for, by that time, the membrane is already forming in the air- 
passages or is already deposited there, and it is too late to obtain the con- 
stitutional effects of the remedy. 

Calomel is the preparation almost always preferred. The doses pro- 
posed by different writers vary considerably, some giving it in large and 
frequently repeated doses, and others in much smaller quantities. I have 
usually given to children of one or two years old, from half a grain to a 
grain, and to those of five or six years of age, or upwards, from one to two 
grains, every two hours. When the symptoms are very urgent, the doses 
may be repeated every hour, for three or four hours, and an emetic of 
alum then administered. If the child be very restless, or if the calomel 
purge much, it is best to combine with each dose a small quantity of 
Dover's powder. 

The whole amount to be given in any case will vary, of course, accord- 



100 PSEUDO-MEMBRANOUS LARYNGITIS. 

ing to its severity and duration. The largest quantity exhibited in any 
one of my cases, was between forty and fifty grains ; the smallest, six. In 
most of the cases the quantity varied between fifteen and thirty grains. 

The administration of calomel in large doses, has not been followed by 
bad consequences in any case in which I have used it. Nevertheless, it 
has been known to produce gangrene of the mouth and necrosis of the 
maxillary bones, and the practitioner cannot be too careful to suspend it as 
soon as may be consistent with safety. I never administer it in this way, 
therefore, without first informing the parents of the possible danger to 
which it exposes the child, and asking their consent to its employment. 

Cauterization of the Fauces and Larynx. — The application of 
astringent and caustic remedies to the fauces, is of great importance in all 
cases beginning simultaneously in the pharynx and larynx. In mem- 
branous angina, when the disease shows any disposition to extend into the 
larynx, the use of these remedies constitutes one of the most essential 
points in the treatment, but of this a full account will be given in the 
article on that disease. In all cases of true croup, however, whether at- 
tended with fibrinous deposit in the fauces or not, I believe it will be found 
useful to employ the nitrate of silver as a local application to the pharynx, 
and low down over the chink of the larynx. I have made use of solu- 
tions of different strength, from five to forty grains to the ounce, and 
prefer, on the whole, one of from ten to twenty grains. This should be 
applied low down into the pharynx, so as to touch the epiglottis, by 
means of a mop made of a small piece of soft sponge fastened upon a bent 
whalebone. The application is to be repeated twice or three times a day, 
or more frequently, according to the violence of the symptoms, and the 
effects of the remedy. 

It will be found, upon reference to some of the later works on diseases 
of children, that writers differ very much in regard to the strength of the 
solution of nitrate of silver employed by them. M. Bouchut, for instance, 
(Trait. Prat, des Mai des Nouv.-Nes. 2eme, ed. 1852, p. 315), recom- 
mends the solution employed by M. Trousseau, containing one part of the 
salt to three of distilled water (ten grammes to thirty grammes.) This is 
applied at least twice, and sometimes three or four times in the twenty- 
four hours, by means of a small sponge on a bent whalebone. The sponge 
is wetted, then slightly squeezed, and conveyed into the pharynx and upon 
the glottis, so that " a few drops of the caustic liquid may penetrate into 
the larynx." M. Bouchut remarks that the treatment has its disad- 
vantages, as " immediate suffocation may be the consequence, should the 
sponge be left too long upon the glottis, and should too large a quantity 
of the liquid enter the glottis." The way to avoid this result is to squeeze 
the sponge slightly so that it may not contain too much of the liquid before 



TREATMENT. 101 

applying it, and then to practise the cauterization rapidly, in order not to 
fill the larynx or oesophagus, as M. Bouchut once saw happen to an inexpe- 
rienced practitioner. M. Bouchut reports three cases of recovery by this 
treatment in connexion with emetics, but says not a word as to failures. 
For my own part, I can only say that I have as yet seen nothing in prac- 
tice that would tempt me to use so powerful a solution as the one just 
mentioned, especially when, as M. Bouchut says, it might be followed by 
instant suffocation. 

Dr. Horace Green, of Xew York, proposed in 1849, the application of a 
nitrate of silver solution into the interior of the larynx, and in a second 
edition of his work (Observations on the Patlwlogy of Croup, etc., Xew 
York, 1852), recommends the same treatment. The solution he employs 
generally is one of forty grains of the pure crystal, to an ounce of distilled 
water. The instrument made use of is a probang formed of a piece of fine 
sponge not exceeding one-third or half an inch in diameter, attached firmly 
to the end of a rod of whalebone, about ten inches in length, and slightly 
curved at one end. The sponge is lightly saturated with the solution, and 
the head of the child being firmly held by an assistant, and the base of the 
tongue depressed by the handle of a spoon, " the operator carries the wet 
sponge quickly over the top of the epiglottis, and on the laryngeal face of 
this cartilage ; then, passing it suddenly downwards and forwards, passes 
it through the opening of the glottis, into the laryngeal cavity/' (Zoc. 
Oit. } p. 84.) Dr. Green recommends that the aperture of the larynx 
should not be passed until after the parts in the faucial and pharyngeal 
region have been prepared by having had the solution applied a few times. 
It is said that after this has been done, the instrument may be passed into 
the larynx, without producing half the amount of irritation its introduction 
below the epiglottis would have awakened without these preparatory steps. 

I have never resorted to this treatment myself, and can therefore give 
no personal opinion in regard to its feasibility or efficacy. The practi- 
cability of the operation cannot now, however, be doubted, since it has 
been performed not only by its author, but by a number of other persons, 
amongst whom I will mention as a disinterested witness, Dr. Charles West, 
of London. Dr. West, in his second edition (Diseases of Children, p. 
258), states that he has employed it but once, " though that case quite 
satisfied me of the possibility of cauterizing the interior of the larynx, and 
even of the absence of any considerable difficulty in accomplishing it." 
As to the results of the treatment, it may well be supposed, that it has 
not been employed by a sufficient number of persons, or in a sufficient 
number of cases, to determine satisfactorily what we are to expect from it. 
Dr. Green reports nine cases treated by himself, of which six recovered — 
a very remarkable success. All of these appear to have been instances of 



102 PSEUDO-MEMBRANOUS LARYNGITIS. 

membranous croup, except perhaps two, case five, of which few details are 
given, and case eight, both of which, from their sudden onset, and sudden 
recovery, seem to me to have been rather attacks of spasmodic or catarrhal, 
than of membranous croup. Dr. John Ware, of Boston, in an essay on 
croup (Boston, 1850, p. 27), reports two cases in which he made use of 
this treatment. The sponge, wet with a solution of the nitrate of silver, 
was introduced into the larynx morning and evening. "It decidedly 
gave relief to the breathing soon after each application, and both cases 
ultimately recovered perfectly." 

I have already referred to the strength of the solution advised by 
M. Trousseau, and to that employed by Dr. Green. Dr. West, I am glad to 
find, prefers one of about a scruple to the ounce, which more nearly agrees 
with the one I have generally made use of. 

In addition to the remedies already mentioned, there are some which 
are supported by high authority at home or abroad. Amongst them are 
the sulphuret of potassium, polygala seneka, and different alkaline prepa- 
rations, especially the carbonate of potash. There is much difference of 
opinion amongst French writers as to the merits of the sulphuret of potas- 
sium, some praising it highly, while others deny it all efficacy. I have 
never used it, and can therefore have no personal opinion in regard to its 
utility. As to the carbonate of potash and seneka, they may be useful as 
adjuvants, but they ought never to take the place of emetics and mercu- 
rials ; for, as time, above all things, is precious in this disease, we should 
never use feeble remedies, to the exclusion of those which are generally 
acknowledged to be more powerful. 

Revulsives often prove useful in allaying restlessness and moderating 
the violence of the suffocative attacks. Sinapisms and mustard poultices, 
applied upon various parts of the cutaneous surface, and mustard pedi- 
luvia, are amongst the best. The warm bath is often highly beneficial in 
the same way. Blisters are sometimes used, but flying sinapisms are pre- 
ferable. 

Antispasmodics are recommended, and are doubtless useful in some 
cases. The best in the world is, in most cases, the operation of an emetic ; 
or, after this, one of the preparations of opium. 

Hygienic Treatment. — The child ought to be warmly clothed and 
confined to bed. The diet should consist only of the mildest fluids during 
the violence of the attack. If the patient become weak and feeble, milk, 
pure or mixed with water, may be allowed, or light broths may be given. 
Towards the termination of favorable cases, the diet must be improved 
slowly and cautiously. If great prostration occur, the powers of the con- 
stitution must be supported by stimulants and tonics, as wine whey, milk 
punch, and quinine. 



TREATMENT. 103 

Summary of the Treatment. — My own conclusions in regard to the 
treatment are that bloodletting is a valuable remedy, when resorted to 
in proper cases, and at the proper moment. In the form which begins as 
angina, and which is generally epidemic, it ought to be used with more 
caution than in that which commences as laryngitis. In the latter form, 
which is usually sporadic, it ought to be used freely, especially in vigorous 
and hearty children. I will suggest the following plan of treatment to be 
pursued in children about or over two years old, when we are called in 
good time : to take from the arm three or four ounces of blood, once, 
twice, or three times in two days, according to the strength of the child, 
and the degree and obstinacy of the fever. In both forms of the disease, 
emetics, and I would recommend alum in preference to any other, should 
be given once at least, very often twice, and in violent cases, three or four 
times in the twenty-four hours, so as to produce vomiting attended with a 
good deal of effort. To give at the same time from one to two grains of 
calomel with a quarter or half a grain of Dover's powder, every two hours, 
taking care not to give a dose for an hour before, nor after the time 
selected for the exhibition of the emetic. In cases in which there is loud 
stridulous respiration, heard both in the inspiration and expiration, in 
which previous treatment has had no effect, and in which there is threat- 
ening of speedy death, we may give two grains of calomel every hour, 
until three or four doses have been taken, and direct the exhibition of an 
alum emetic, after the last dose, or resort to tracheotomy. 

Nine of the seventeen cases so often referred to were fairly treated by 
the mixed method just described. Of the nine, two died, and seven reco- 
vered. One I saw with Dr. Rutter of this city, one with Dr. EL H. 
Smith, two with my father, and five I attended myself. One of the nine 
was not, however, cured by these means. This was the case already 
mentioned in the remarks upon mercury, as seeming to show that the 
medical treatment had restricted the exudation to the larynx and trachea, 
and thus prepared the child for a favorable termination of the operation 
of tracheotomy, though the remedies had foiled to remove the disease 
from the upper air-passages. 

TRACHEOTOMY. 

The operation of tracheotomy would suggest itself naturally to any 
medical man, on his witnessing the closing symptoms of croup, as the 
very means most likely to afford relief to the dreadful sufferings under 
which the patient is writhing, and a rescue from approaching death. 
Tracheotomy has accordingly been often resorted to in different parts 
of the world, at various stages of the disease, but with results that 
have led to very different conclusions. In England, for example, it 
has been of late years almost universally abandoned. Dr. Williams (Lib. 



104 TRACHEOTOMY. 

Prod. Med., vol. ii. p. 256) is opposed to the operation, because of 
its daugers, of the few chances of success it affords, and because "it 
has been decidedly negatived by Dr. Cheyne, Mr. Porter, and other 
of the best authorities." He states that, " in general it can scarcely be 
said that the performance of the operation is justifiable." Mr. Porter 
(Surg. Obs. on the Larynx and Trachea, p. 64) says, "I have known 
and heard of it often, but never understood that it produced a recovery." 
Mr. Kyland (Lis. of Larynx, p. 159) remarks : " With regard to the 
general results of tracheotomy, when performed for the cure of croup, I 
have no hesitation in saying that they are so unfavorable as to warrant 
us in the strongest condemnation of it under almost every conceivable 
circumstance." Dr. Charles West (Lis. of Infancy and Childhood, 2d 
edition, London, p. 253) hesitates in expressing a decided opinion against 
tracheotomy, and does not join at present " in the unqualified condemna- 
tion of the operation in cases of croup, which has been pronounced by the 
greater number and the most weighty of English authorities." 

Put while tracheotomy has fallen into such ill-favor in England, it 
has been gradually rising into repute in France, until, within a few years 
past, it has been established as a proper and legitimate method of treat- 
ment under certain circumstances of the disease. M. Bretonneau, of 
Tours, was the first who practised it with sufficient success in France to 
give it some vogue. Since that time, it has been recommended and per- 
formed by many different surgeons and physicians in that country, and 
particularly, as is well known, by M. Trousseau, who has been, undoubt- 
edly, the most ardent and persevering, as well as the most experienced 
advocate of the operation. 

As I have already quoted the opinions of some of the most weighty 
authorities in England, as to the propriety of the operation, it is but fair 
that I should do the same in regard to the French ; for, though we are 
more governed perhaps in this country by English than by French opinions 
there can be no doubt that upon all medical questions, the latter are 
well deserving of our utmost consideration. 

The opinions of MM. Bretonneau and Trousseau have already been 
referred to. M. Guersent (Diet, de Med., t. ix. p. 376) recommends the 
operation when the usual therapeutical methods have failed, " as the only 
means which offers a remaining chance." He adds (p. 377), that he is 
certain it does not add to the danger of the disease. Rilliet and Barthez 
(Mai. des Enfants, t. i. p. 366) say that when medical means have been 
used without success, and the patient is distressed, laboring under re- 
peated suffocative attacks, complete aphonia, and marked stridulous respi- 
ration, etc., " we ought not to hesitate to have recourse to tracheotomy." 
The authors of the Compendium de Medecine Pratique (vol. ii. p. 587), 
remark that of late years " the successful operations have been numerous 



TRACHEOTOMY. 105 

enough to dispel the unfortunate prejudices which tracheotomy had 
hitherto inspired." Valleix (Guide du Med. Prat., t. i. p. 388) says 
that the number of recoveries are " now too numerous to allow any one 
to think of opposing the operation except by statistics." MM. Hardy and 
Behier (Trait, de Pathol. Int.] 1850, t. ii. p. 496), in speaking of the 
contest in regard to the propriety of the operation, say : " But the ques- 
tion seems now to be definitively settled ', the operation has succeeded, in 
fact, in a little more than a fourth of the cases in which it has been 
performed, and in presence of these results, it may be said to become the 
duty of the physician to have recourse to it whenever, notwithstanding an 
appropriate treatment, the general and local symptoms indicate the ex- 
tension of the false membrane." M. Bouchut (Trait, des Mai. des Xou.- 
Nes, 2eme ed. p. 316) says that when medical means fail, and the disease 
has produced a " state tending towards asphyxia, in which an attack of 
suffocation might cause the death of the child, there should be no hesita- 
tion ; a new route must be artificially opened to the external air ; tracheo- 
tomy must be performed." 

In this country the operation has been performed from time to time by 
different persons, but generally, it must be confessed, without success. 
It is opposed by Drs. Dewees and Eberle, and is spoken of by Dr. 
Stewart, of New York, as a desperate resource. Dr. Condie (Dis. of Chil- 
dren, 3d ed., p. 332), speaks of it in the following terms : " That it may, 
in many cases, when timely performed, save the life of the patient, we 
have the most unquestionable evidence." Dr. Condie makes no mention 
of any personal experience in the operation. 

For my own part, I am clearly convinced from what I have seen of the 
operation, from my reflections upon the nature of the disease and opera- 
tion, and from the results obtained by the French physicians and surgeons, 
that tracheotomy is, to say the least, entirely justifiable, if not perempto- 
rily indicated, under certain conditions of croup. 

In a consideration of the propriety of this operation in croup, there 
are, it seems to me, two points in particular to be examined : 1. Whether 
it offers any chance of success whatever ; and 2, Whether it is in itself 
dangerous. Now, in regard to the first point, we find, on consulting the 
English medical authors, that they are almost universally of opinion 
that it is scarcely ever successful, and therefore unjustifiable. When we 
turn to the French writers, on the other hand, we find that most of 
the recent authoritative writers on the diseases of children and on prac- 
tice, recommend it as a legitimate method of treatment, and even press it 
upon us, as offering much additional chance of safety to the patient. 
The success of the operation amongst the French has been as follows : 
M. Bretonneau had six recoveries in twenty operations ; M. Leclerc, of 



106 TRACHEOTOMY. 

Tours, bad one in two; M. Yelpeau, two in ten, and M. Petel, three in 
six (RiRiet et Bartlicz, Mai des Fnfants, t. i. p. 379). M. Valleix 
(Loc. cit., p. 389) states that he found, upon examining into the results 
of tracheotomy, that the operation had been successful in nearly one out 
of three. M. Trousseau, who has performed the operation so much more 
frequently than any one else, is said to have had one hundred and thirty- 
five operations, of which only one in four was successful, up to the year 
1850 {UAhclUc Medicate, June 1st, 1852, p. 146). Since 1850, his 
success has been much greater, owing to certain modifications in the 
canula he employs, and in the after-treatment of the case. In 1850, he 
had six operations, and in the first months of 1851, eleven. Of the seven- 
teen seven were successful. The same modifications have been introduced 
into the Children's Hospital at Paris, and with the following results. In 
the space of fifteen years, more than forty operations had been performed 
without a single cure. In 1850, after the changes just referred to had 
been made, nineteen operations were performed, of which six were suc- 
cessful, and in the first seven months of 1851, sixteen were performed, 
of which seven ended favorably (V Abeille Med., loc. cit.) Of the modi- 
fications made by M. Trousseau, in his methods, I shall speak hereafter. 

The operation has not, I believe, been performed very frequently in this 
country, as I can find but few examples of it on record. Dewees, however, 
mentions two operations by Dr. Physick in this city, both of which proved 
fatal. Two are reported in the Transactions of the New York Academy 
of Medicine (vol. i. part i., 1851), — one by Dr. Yan Buren, and the other 
by Dr. Buck. The former was unsuccessful, the latter successful. Ano- 
ther operation, which failed, is described by Dr. William Pepper of this 
city ( Trans, of the College of Physicians of Philad., Yol. III. No. III. 
p. 106). Dr. Page, of this city, has kindly given me the details of a 
case in which he operated. It was that of a girl, aged three years, who 
was attended by Dr. Leib from October 4th, 1851, to October 9th, during 
which time calomel and Dover's powder, and emetics, were freely given, a 
blister applied, and topical applications made to the fauces. On the 9th 
October, the ninth day of the disease, finding the patient very much op- 
pressed, anxious, somewhat cyanosed, and rapidly sinking, Dr. Leib sent 
for Dr. Page to perform the operation. This was done without any diffi- 
culty other than a profuse venous hemorrhage, which was, however, only 
momentary, as it was instantly checked. A triangular piece was removed 
from one of the rings of the trachea. The mercurial treatment was 
continued, and the patient did well until midnight of the 11th, when she 
began to sink, and died on the morning of the 12th, about sixty-two 
hours after the performance of the operation. Dr. Keating, of this city, 
has had the operation performed twice in his practice, once by Dr. Pan- 



TRACHEOTOMY. 107 

coast, and once by Dr. Goddard. The former operation was successful, 
the latter failed. I have had it twice performed in my own practice by 
Dr. Pancoast : one terminated favorably, the other not. In a third case, 
which occurred in the practice of my father and myself, the operation 
was also performed by Dr. Pancoast, and was successful. Dr. H. H. 
Smith, in his recent work on Operative Surgery (Phila. 1852), gives a 
table of tracheotomy operations in croup performed in this country, 
amounting to fifteen in number. Of the fifteen, four of those by Dr. 
Pancoast, one by Dr. Page, one by Dr. Van Buren, and one by Dr. Buck, 
I have already alluded to, so that there remains only eight for present 
consideration. All of these eight were fatal. Since the publication of 
Dr. Smith's work, Dr. Pancoast has had another operation, which proved 
fatal. 

We have ascertained now that the mortality from the operation was 
one in three or four in France up to 1850, and during 1850 and the first 
seven months of 1851, about one in two and a half (thirty-two in fifty-two). 
I have collected the results of nineteen operations in this country, and it 
must be confessed that, though more favorable than those obtained in 
England, they have not been flattering, since only four of the nineteen, 
or a very little less than one in five, were successful. 

Now, in order to form an opinion as to the real merits of the operation, 
it is necessary to have some idea as to the number of subjects that might 
have recovered without a resort to it. This is very easily arrived at in 
this country, since it is never performed here except as a last resort, when 
the patient is manifestly in great danger of death, or absolutely moribund. 
In the three cases that occurred in my own and my father's practice, I 
have no hesitation in believing that death would have been the inevitable 
result in all but for the operation, whereas by that two were saved. In 
regard to the French operations it is not so clear whether some of the 
patients, who recovered after the operation, might not have been as for- 
tunate without it, particularly as M. Trousseau recommends that it be 
performed as soon as we can be certain that the larynx contains false mem- 
branes. But then it is generally understood that he was not called to 
many of the cases upon which he operated until all other means had 
failed, and the child had fallen into an apparently hopeless condition. To 
elucidate this matter, I shall quote the statements made by M. Valleix, 
one of the most accurate and impartial of writers, whose fairness and love 
of truth do honor to himself and to the nation to which he belongs. Bf. 
Valleix (Loc. cit. p. 388-9) tells us that he collected together fifty-four 
cases of undeniable, well-marked true croup, treated without the operation, 
and found that seventeen had been cured. Then, examining what had 
occurred in regard to the operation, he found, as M. Bricheteau had done 



108 TRACHEOTOMY. 

before, that nearly one in (Jure had recovered, a success almost precisely 
the same as had taken place in the cases treated by medical means alone. 
"But," he goes on to remark, "there is a consideration of very great 
importance, one which gives an altogether different importance to tracheo- 
tomy, to wit, that in the immense majority of instances, the operation 
was performed under the most discouraging circumstances, and only when 
all other methods of treatment had proved useless, and the severity of 
the symptoms, and the near approach of asphyxia, indicated impending 
death. "Who can fail to see that a single cure, under such circumstances, 
is of much greater weight than several obtained in cases against which all 
the resources of the art had been applied from the first V 1 We have here 
the evidence of a most competent witness, living on the spot, to convince 
us that the operation is not resorted to in France, at least generally, 
early in the disease, but is performed only as a last resource, when the 
chance for the patient from the efforts of nature, or from medical means, 
is almost null. How, then, can we resist the conviction that tracheotomy 
does afford a sufficient probability of success, after other means have 
failed, and death is fast approaching, to render a recourse to it at least 
justifiable, if not almost compulsory ? 

The second point to be examined, in regard to the propriety of the 
operation is, whether it be in itself dangerous. 

From all that I can learn, it appears that the only serious danger 
attendant upon the operation is the occurrence of hemorrhage. When 
performed for the removal of foreign bodies from the air-passages, the 
patients almost always recover, if the foreign body do but escape. Olli- 
vier (Article Larynx, Corps Etrangers, Diet, de 3fed.), says that the 
success of the operation is, so to speak, certain, when it is performed early. 
Liston disapproves of the operation in croup, but states that it is not at- 
tended with much danger. Skey regards it as an operation of some diffi- 
culty and danger, from the irregularity in the distribution of the vessels, 
and the existence of numerous veins, which may bleed profusely. Boyer 
does not regard it as dangerous, and states that the only danger is from 
the occurrence of venous hemorrhage into the trachea, and not from 
the amount of the loss of blood. Chelius says that it is dangerous below 
the cricoid cartilage from anastomosis of the thyroidean arteries, from the 
presence of venous plexuses, and sometimes from a deep thyroidean artery. 
A elpeau speaks of the venous hemorrhage as alone dangerous. Lastly, 
M. Trousseau, who has had more experience in the operation by far than 
any one else, states (Rilliet et Barthez, Loc. cit.) that he has performed 
it one hundred and twenty-one times, and has met with but a single acci- 
dent in all of these. In this case, performed in a man fifty-two years old, for 
a laryngeal disease causing extreme suffocation, an epileptiform convulsion 






TRACHEOTOMY. 109 

occurred just as he was making the first incision. He imprudently con- 
tinued (to use his own words), when a second convulsion occurred, and 
was immediately fatal. M. Trousseau remarks that tracheotomy and 
laryngo-tracheotomy, performed to remove foreign bodies, "are never 
scarcely followed by fatal accidents : the operation is not therefore in 
itself dangerous." Dr. Pancoast of this city, who has operated in eight 
cases of croup, and a number of times for the removal of foreign bodies in 
the air-passages, has never met with any serious difficulty in the perform- 
ance of the operation, nor with any accident which he could suppose might 
have affected the life of the patient. Dr. H. H. Smith (Loc. cit. p. 262) 
gives a table of twenty-nine operations for the removal of foreign bodies 
from the air-passages, all performed in this country, and of these but one 
ended fatally. Dr. Smith remarks that from a " comparison of these two 
tables (including operations for croup and those for the removal of foreign 
bodies), it is very evident that the dangers which ensue upon incising a 
healthy trachea are comparatively slight, and that the great mortality 
which has attended the operation, when performed for the relief of croup, 
must be due to some other cause than the mere incision of the windpipe." 

From the above quotations in regard to the danger from the mere 
operation itself, setting aside that from the disease or accident for which 
it is performed, it would appear that the only serious risk is from hemor- 
rhage, and that this, though it. is alluded to by many surgical writers, 
cannot be very great, since twenty-eight out of twenty-nine operations, 
performed for the removal of foreign bodies, were successful. 

I think it has now been shown, by citations of the opinions of persons 
experienced in the operation, and by statements of the results obtained 
from it in France and this country, that it does really offer some addi- 
tional means of safety to the patient, after the failure of all proper medical 
means. That it has saved the lives of some, at least, of the numerous 
subjects upon whom it has been performed, which would otherwise have 
been lost, no reasonable and unprejudiced person can, it appears to me, 
deny. That some who have been operated upon might have recovered 
without it, I do not doubt; but the uncertainty as to the absolute 
necessity of resorting to it in any individual case, is not greater, probably, 
than that which exists in regard to a great many other surgical operations, 
and to many medical applications. 

It has also been shown, I think, that the operation is, in itself alone, 
but slightly dangerous to life, at least when performed by a firm and 
dexterous hand. This removes, of course, the only very serious objection 
to it, since if the risk from the incision add but little to the danger of the 
patient, we may venture a resort to it for its probable chance of good, 
even though that chance be still one only moderate in degree. 



110 TRACHEOTOMY. 

If we decide that tracheotomy is a justifiable operation in croup, it 
becomes all-important to determine the period of the disease at which we 
should have recourse to it. M. Trousseau has laid down the rule, that it 
is to be performed so soon as we can be certain that false membranes have 
formed in the larynx. He fixes upon this as the proper moment, because 
he believes that death is, under these circumstances, almost inevitable. 
But we have already learned from M. Valleix, that of fifty-four perfectly 
well-marked cases collected by himself, treated medically (without the 
operation), seventeen, or about a third, recovered. If we add to this that 
of sixteen cases seen by myself, six recovered without the operation, it 
becomes very clear, I think, that the mere certainty of the presence of 
the exudation in the larynx, is not sufiicient warrant for a resort to the 
operation. And, indeed, most authorities advise that we should wait 
until medical means Jiave been fairly tried, a course almost universally 
pursued, I believe, in this country. When, however, these means have 
been tried, and when, in spite of them, the condition of the patient is 
becoming aggravated, when the dyspnoea, stridor, aphonia, and gradual 
progression of the symptoms, and when, particularly, the appearance of 
asphyctic phenomena denote an increase of the laryngeal obstruction, the 
operation, if it is to be thought of at all, ought to be proposed. In one 
of the cases that occurred in my practice, and which ended favorably, 
the symptoms had gone even further than this, for the bluish skin, 
drowsiness, and insensibility to pain, showed that the patient had already 
sunk into a very dangerous asphyctic condition. The operation ought 
not to be attempted under certain conditions, as, for instance, that of the 
existence of double pneumonia. Pneumonia of a single lung is not, 
however, according to M. Guersent, a contra-indication. The presence of 
any serious organic disease renders it improper of course. There is 
another condition of the disease which, could it but be detected, ought to 
constitute an insuperable bar to the operation, and the possible existence 
of which, in any case, is one of the most serious objections that has been 
brought against it. The condition to which I allude is the presence of 
the pseudo-membranous exudation in the bronchia. The existence of this 
condition must, indeed, render it almost impossible for the patient to 
recover, and would make it altogether improper to subject the child to an 
operation from which no good could be reasonably expected. But, unfor- 
tunately, there are no means by which we can determine with certainty 
whether the disease has extended to the bronchia or not. It was at one 
time thought that auscultation might afford the desired information, but 
more careful observation has shown that it is not to be depended upon. 
I have already said, that in most cases the laryngeal stridulous sound is 
so loud as to mask all chest-sound, and the following cases show that, 






TRACHEOTOMY. Ill 

even when this does not happen, very little is to be learned from phy- 
sical examination. The first case I shall refer to is one mentioned by 
De La Berge and Monneret (Comp. de Med. Prat., t. ii., p. 587), in 
which they could not believe that the bronchia contained false mem- 
branes, as the vesicular murmur was extremely pure, and was heard 
everywhere ; and yet, during the operation, a false membrane was drawn 
out, which represented the trachea and the division of the principal 
bronchia. The child died in fifteen hours. Dr. Wm. Pepper, of this 
city, reports two fatal cases (Summary of Trans. Coll. Phys., vol. iii., 
No. iii. p. 106), in one of which u distinct vesicular murmur could be 
heard throughout the lungs, marked only, occasionally, by sibilant and 
sonorous rattles/' a few hours before tracheotomy was performed. The 
child died twenty hours after the operation, and the exudation was found 
to implicate the larynx, trachea, the large bronchia, and even some of the 
smaller ramifications. In the other case, the state of the respiration was 
carefully examined the day before death, and not the least respiratory 
murmur could be heard over any part of the chest, and yet, in this 
instance, the exudation was confined strictly to the larynx, — not a vestige 
of false membrane was to be found either in the trachea or bronchia. 
These cases show clearly, it seems to me, that little or nothing is to be 
gained from auscultation in elucidating this important point. 

In a published account of several cases of this disease (Am. Journ. 
Med. Set., April, 1849, p. 332), I suggested that we might infer, with 
some probability, the extent of the exudation, by a careful consideration 
of the history of the case, and of the general symptoms. From an exa- 
mination of four cases, in which the extent of the exudation was ascer- 
tained, either by the operation, or by post-mortem examination, I found 
that the pulse was much less rapid, during the course of the disease, in 
those in which the membrane was confined to the larynx alone, or to the 
larynx and trachea, than in those in which it had invaded the bronchia. 
Thus, in two cases in which the bronchia were implicated, the pulse 
counted from one hundred and forty to one hundred and fifty for several 
days before death in one, and one hundred and sixty-four just before the 
operation in the other ; while in two others in which only the larynx 
and trachea were diseased, it was one hundred and thirty in one, and 
in the other between one hundred and twenty and one hundred and thirty. 
Moreover, in the case reported by Dr. Pepper, in which the disease was 
found strictly confined to the larynx after death, the pulse was only one 
hundred and twenty the day before the fatal event. In the other case 
by Dr. Pepper, in which the bronchia were implicated, the state of the 
pulse is not given ; it is merely stated that it was frequent and feeble just 
before the operation. I shall conclude my remarks upon this point, by 



112 TRACHEOTOMY. 

suggesting, that, in all probability, not only would the pulse throughout 
the attack be more frequent, but that also the signs of asphyxia will have 
lasted longer, and have come on more slowly and gradually, in cases in 
which the bronchia are diseased, than in those in which they are not. 

But, even if we adopt the worst view of the case, and conclude that 
it is impossible by any means now within our reach to determine the 
extent to which the exudation may have invaded the air-passages, it is 
still very doubtful whether we ought for that reason to abandon the opera- 
tion. In effect, it has been well established by numerous observations, 
which the reader will find mentioned at page 85, that the membrane extends 
into the bronchia only in a third of the cases, leaving two- thirds in which 
it remains limited to the larynx alone, or to the larynx and trachea. The 
question becomes, therefore, one of expediency, whether to leave two- 
thirds of the patients, some of whom might be saved by the operation, 
to perish without an effort to save them, because one-third must die in 
spite of it; or to perform it uselessly in a third, for the sake of the chance 
of saving some of the remaining two-thirds who must otherwise die. 

Operation. — I shall not pretend to describe the operation, but must 
refer the reader to the works on surgery, to the article on tracheotomy by 
M. Valleix (Loc. cit., p. 386), to the one by M. Trousseau, in the first 
volume of the work of MM. Billiet and Barthez, to that by the same 
writer in the Dictionnaire de Medicine (t. ix., p. 381), or to the recently- 
published work of Dr. Henry H. Smith, of this city, on Operative Sur- 
gery, in which will be found an account of the various modes of operating, 
and particularly of the one employed by Dr. Pancoast, which appears to 
me to be much the best. I deem it necessary, however, to call attention 
to a peculiarity of Dr. Pancoast' s mode of operating, and to some modifi- 
cations recently introduced by M. Trousseau, in the kind of canula he 
employs, and in the after treatment of his patient. 

The peculiarity of Dr. Pancoast' s operation consists in the circumstance 
of his excising a portion of the walls of the trachea. This method was 
first recommended, apparently, by Mr. Lawrence, of London, was success- 
fully employed on one occasion by Mr. Carmichael, of Dublin, and is now 
adopted by Dr. Pancoast, in order to avoid the necessity of employing 
canulas or dilating instruments, which cannot but be more or less irrita- 
ting and injurious. Dr. Pancoast, in the case which he describes, excised 
" an elliptical piece from the front part of the third, fourth, and fifth 
rings of the trachea." " The piece excised in this case was about a third 
of an inch long, by about two-tenths of an inch broad." Dr. Pancoast 
holds apart the edges of the wound made in the soft parts over the 
trachea, by means of a piece of thick leaden wire bent so as to form hooks 
at either end. The wire is of such a length as to fit accurately when the 
hooked ends are placed within the edges of the incision, around the neck, 



TRACHEOTOMY. 113 

and thus keeps up just sufficient traction in opposite directions to main- 
tain the wound open. 

The modifications made by M. Trousseau are the following (see L'Abeille 
Medicate, Loc. cit.) In the first place, the patients, owing to a general 
change in the mode of treatment of croup, are in a better condition for 
the operation than formerly. The treatment consists usually of cauteriza- 
tion of the fauces with a very strong solution of the nitrate of silver (one 
part to three of water), of insufflations of alum into the throat, and 
emetics. Bleeding and blisters are generally avoided, as both are thought 
to be injurious, the former by debilitating the patient, and the latter 
because they are painful, useless, and because they become covered with 
false membranes, which have sometimes caused the death of the patient, 
when the operation has been otherwise perfectly successful. 

In the second place, M. Trousseau has abandoned the use of the caustic 
instillations into the larynx and trachea, which he formerly employed in 
every case. He rarely makes use even of emollient injections. He 
now employs only a double canula instead of a single one as formerly, 
which latter he was obliged to remove two or three times in the twenty- 
four hours, a proceeding always painful and nearly always difficult 
during the first two days. Now, the parents remove the internal canula 
every few hours, or as often as it becomes clogged, and clean and replace 
it without causing pain or irritation. Formerly, the neck being left exposed 
to the air, the mucus in the canula and trachea dried up, and he resorted 
to frequent instillations of water, and a process of swabbing out with a 
sponge-mop, in order to remove these obstructions. Now, so soon as the 
operation is finished, he envelopes the neck in a cravat, so that the expired 
air is in part inhaled again, thus preserving its warmth and particularly its 
moisture. By this proceeding, the drying up of the mucus in the 
trachea and bronchia is avoided, expectoration is much easier, and injec- 
tions and swabbing are no longer necessary. M. Trousseau formerly 
left the wound exposed to the air, contenting himself with dressing it 
sometimes with a little charpie covered with cerate. The wound became 
covered with false membranes, inflamed violently, and sometimes became 
even gangrenous. Now, he places over the charpie a piece of waxed silk, 
pierced with a hole for the passage of the canula, by which means the 
incision is protected doubly by the cravat and by the shield of waxed 
silk. On the day after the operation, he cauterizes vigorously all the 
divided parts which become covered with false membranes, and repeats 
the cauterization two or three times until the surface of the wound is 
perfectly clean. 

The very great improvement in the results of the operation, since these 
modifications have been carried out in M. Trousseau's practice, and also in 
the Children's Hospital at Paris, have been already mentioned at page 106. 



CHAPTER II. 

DISEASES OF THE LUNGS AND PLEURA. 
GENERAL REMARKS. 

It would be difficult, perhaps, to over-estimate the importance to the 
medical practitioner of a thorough knowledge of the different diseases of 
the lungs and pleura, as they occur in children. The diseases of the 
respiratory organs, — and much the most frequent of them are pneumonia 
and bronchitis, — cause, according to Dr. West, of London, very nearly a 
third of all the deaths under five years of age in England ; while not above 
one child in four dies under that age from diseases of the nervous system, 
and not above one in seven from those of the digestive system. In this 
country, it would seem from the bills of mortality that a larger proportion 
of children die of diseases of the digestive than of the respiratory system. 
But while this is true, there can be no doubt that the diseases of the latter 
system are deserving of our utmost attention, since not only are they of 
constant occurrence, and of fatal tendency, as idiopathic affections, but 
since also they frequently appear as complications in the course of other 
diseases, adding greatly thereby to their severity and danger. In measles, 
for instance, by far the most frequent cause of danger is the occurrence 
of some inflammation of the lungs or pleura. The same is true of hoop- 
ing-cough. In scarlet fever and typhoid fever, bronchitis and pneumonia 
are very common accidents, and recent researches have shown that in all 
states of great debility and prostration, a certain change in the condition 
of the pulmonary tissue, to which the term collapse has been applied, is 
very apt to occur. 

The morbid condition of the lung last referred to, that of collapse, is 
one that has been well understood only within a few years past, and yet 
it is such an important one, in a practical point of view, as to excite a feeling 
of surprise that it had not been discovered before. 



ARTICLE I. 

ATELECTASIS PULMONUM, OR IMPERFECT EXPANSION OP THE LUNG. 

The title of atelectasis pulmonum, from arsXnjg, imperfect, and sxroKf^, 
expansion, was first employed by Dr. Edward Jorg, to designate a con- 



ATELECTASIS. 115 

dition of the lung observed by him in new-born children, in which larger 
or smaller portions of those organs had never been penetrated by air. 
The child had established its respiration at birth more or less imperfectly, 
and some parts of the pulmonary tissue had consequently never undergone 
expansion under the distending influence of the inspiratory act ; these 
undilated parts continued in the foetal state. 

In addition to this congenital form of imperfect expansion of the lung- 
tissue, this condition is met with at all ages of life, though with especial 
frequency in young children, as the consequence of a collapse of portions 
of the once expanded lung, or, in other words, of their return to the foetal 
or unexpanded state. To this latter form of imperfect expansion the 
terms post-natal atelectasis, collapse, and foetal condition, have been given. 
Before the discovery of its real nature was made, it had often been de- 
scribed also under the well-known names of carnification and lobular 
pneumonia. I shall designate it by the title of collapse, or post-natal 
atelectasis, while under that of congenital atelectasis pulmonum, I shall 
describe the congenital variety of imperfect expansion. 

CONGENITAL ATELECTASIS. 

Anatomical Appearances. — In congenital atelectasis the parts of 
the lung most frequently affected are the posterior portion and lower edge 
of the inferior lobes, the middle lobe of the right lung, and the languette 
and lower edge of the upper lobes. In some instances, as in one examined 
by myself, the greater part of the lower lobes of both lungs, while in 
others, still larger portions of these organs, have been found to present 
this condition. The imperfectly expanded portions of the lung are of 
a dark red, or purplish color, and are diminished in size, so as to be de- 
pressed below the level of the healthy parts. They are solid to the touch, 
and yet they have not lost their cohesive properties, as they are neither 
friable, easily torn, nor readily penetrable by the finger ; their cut surface 
is perfectly smooth ; they do not crepitate under the finger, and no air 
bubbles are seen in the fluid squeezed out by pressure ; they sink when 
thrown into water. They, in fact, resemble exactly the foetal lung. The 
most convincing proof of the real nature of this condition is obtained by the 
inflation of the lung. When this is done, the depressed, hard, and dark- 
colored portions, unless the subject from whom the specimen has been 
taken may have lived long enough to have allowed the different tissues of 
the lung to become adherent, rise to their natural level, become elastic, 
soft, and crepitating, and change, under the influence of the entering air, 
from a dark and livid tint, to the rosy or pink color of healthy pulmonary 
tissue. In recent cases, this inflation is performed with great ease, and 



116 CONGENITAL ATELECTASIS. 

with perfect success, while in other instances, in which the child has lived 
for some weeks or months, the distension is either effected only by strong 
efforts, or in a very imperfect manner, or it may fail entirely, owing to 
some permanent change having taken place in the tissues of the unex- 
panded portions. In a case that occurred to myself, the subject of which 
died at the age of fourteen months, of acute pleurisy of the right side, 
after having presented at birth and throughout its short life many of the 
symptoms of atelectasis, the inferior two-thirds of the lower lobe of the 
left lung exhibited in the greatest perfection all the atelectasial charac- 
teristics. The whole of the unexpanded part was distended by means of 
inflation with a blowpipe, but only after repeated and powerful expiratory 
efforts, and my friend, Dr. E. Wallace, who made the examination, 
assured me that he was obliged to use a degree of force much greater 
than he ever employed to inflate healthy adult lung. 

In most cases, the foramen ovale and the ductus arteriosus are found 
to be still open, or the latter has but partially closed. 

The causes of congenital atelectasis have not been satisfactorily ascer- 
tained. The only conditions that have been well made out as probable 
causes are : original debility of the infant, from any cause that has inter- 
fered with its proper development in utero, as feeble health on the part of 
the mother during pregnancy, or multiple pregnancy ; and acquired 
debility, brought about by the fact of the infant's being exposed at birth 
to unfavorable hygienic influences, and particularly to those which inter- 
fere with the proper performance of the respiratory act, as cold, a vitiated 
and close atmosphere, and the use of too heavy or tight clothing. A very 
hurried and rapid labor has been thought to cause, in some instances, this 
imperfect expansion of the lung-substance. In one case that occurred to 
myself (See Am. Journ. Med. Sc. y Jan. 1852, p. 83), the only explana- 
tion of the condition, which seemed at all plausible, was that the placenta 
had been separated from the uterus at too early a period of the labor, in 
consequence of the violent and rapid character of the latter, so that the 
child was for a short time before birth cut off entirely from its connexion 
with the mother, — a time sufficient so to lower its vital forces, as to bring 
on a condition resembling syncope, and to deprive it of the muscular 
strength necessary on entering the world, to produce a full expansion of 
the thoracic cavity, and so of course to effect a dilatation of all parts of 
the lungs. 

Symptoms. — The symptoms depending on congenital atelectasis vary 
a good deal in different cases. There are some, however, which exist in 
most of the cases. These are the following : the child comes into the 
world feeble and weak, and instead of crying vigorously and loudly the 
moment or very soon after it is born, it fails to cry at all, or the cry is 



SYMPTOMS. 117 

low and weak, or it is whimpering or wailing ; the color, instead of being 
brick-red or dark-red, is pale and whitish, leaden, or livid ; the muscular 
movements, which in healthy children, are strong and vigorous, are in 
these, languid and slow, or there are none or scarcely any, the limbs 
being relaxed and motionless. If the breathing is observed, it is found 
to be short, high, and imperfect, and it is evident that the thorax is but 
imperfectly dilated at each movement of respiration. When these symp- 
toms exist in a very marked degree, the infant either dies soon in a state 
of asphyxia, or, the muscular force slowly increasing, the respiration 
gradually improves, and the child is, after a longer or shorter time, either 
out of danger, or it falls into the same state as that of one in whom the 
symptoms have been from the first less severe. Under the latter circum- 
stances, the infant continues feeble and weak. It breathes shortly, 
rapidly, and imperfectly, but often without any appearance of labor. 
The cry is rare, and when heard, is low and feeble, or, there is a constant 
plaintive moan, which is very characteristic, and strongly expressive of 
exhaustion, with each respiration. The color continues pale and whitish, 
or it is bluish, and the temperature of the extremities is lower than natural. 
The child sleeps the greater part of the time, and is unable to nurse or 
nurses very feebly, but can swallow when fluid is poured into the mouth. 
In such cases as these, the infant does not necessarily die, but will often 
recover when properly treated. In favorable cases, the symptoms just 
enumerated may last from a few hours to a day or two, or even a few 
weeks, without much change; then, under the influence of correct hy- 
gienic and medical treatment, they will often begin to improve. The 
color becomes less pale or less bluish ; the muscular movements are some- 
what stronger; the child begins to cry, and in a louder tone; the act of 
swallowing is easier and more perfect, or the infant is able to suck when 
applied to the breast, at first feebly and only for a moment, and then more 
strongly; the respiration becomes slower, fuller and more natural, and 
gradually the dangerous symptoms disappear. 

In unfavorable cases, on the contrary, the respiration fails to improve, 
but becomes more and more short, quick, and imperfect ; the temperature 
of the body falls ; the color of the surface changes, becoming leaden, 
bluish, or even livid, the change showing itself first in the neighborhood 
of the mouth, and in the hands and feet, and extending gradually to the 
rest of the body; the difficulty in swallowing becomes greater, and very 
generally some spasmodic twitchings begin to show themselves about the 
muscles of the face. The respiration is very often attended with slight 
wheezing or rattling, and the convulsive movements returning frequently, 
and becoming more violent and more general, the child dies in convul- 



118 CONGENITAL ATELECTASIS. 

sions, or it sinks very slowly and gradually, without convulsions, as though 
in a state of syncope. 

There is another symptom of imperfect expansion of the lungs in 
new-born and very young infants, which ought not to be passed unnoticed. 
It is one mentioned by Dr. George A. Rees, of London, in an essay on 
this subject (London, 1850), and is regarded by him as the pathognomonic 
symptom of the condition. It is an altered movement of the ribs in respi- 
ration. During the inspiratory effort the ribs are seen to move inwards 
towards the mesial line of the trunk, instead of outwards as in ordinary 
respiration, thus diminishing, instead of expanding the transverse diameter 
of the thorax. The explanation of the altered movement is as follows : 
When the diaphragm descends, the lung ought to expand in such a way 
as to fill up the increased space produced in the thoracic cavity by the de- 
scent of that great muscle. Instead of this being the case, however, the 
lung is collapsed and inexpansive, and cannot enlarge sufficiently to fill 
up the space alluded to, so that there would remain a vacuum in the chest 
were it not that the thoracic walls are driven inwards by the pressure of 
the atmosphere upon their outer surface. In a case that I saw myself in 
a child fourteen months old, who had presented symptoms of atelectasis 
from birth, and in whom I found after death very extensive collapse, this 
symptom was very marked. The base of the thorax was indented on both 
sides by a deep gutter or depression, which remained depressed and un- 
changed during the inspiratory movements, or which, indeed, rather be- 
came more distinctly visible during those motions, so that the chest pre- 
sented the curious spectacle of dilatation or expansion in its upper parts, 
during inhalation, and of contraction or collapse at its base. 

Symptoms of Collapse in the early "Weeks or Life. — Before 
taking up the regular consideration of post-natal collapse, as it occurs at 
all ages of childhood, I wish to refer, for a moment, to that condition as 
it appears in the first few weeks of life, in infants who have exhibited 
no sign of it whatever, perhaps, at the moment of birth. I desire to do 
this now, because the symptoms which it gives rise to resemble much 
more those of congenital atelectasis, than those of collapse in children 
over a few months old. And let me remark, that these symptoms are 
very different, and much more severe and threatening than those of 
collapse at later periods. I am myself disposed to believe, though I for- 
merly thought differently, that a principal cause of the great difference 
between the symptoms of congenital atelectasis, as well as of post-natal 
atelectasis occurring in the first few weeks of life, and the collapse of 
later periods, is to be found in the fact that the foetal openings, the 
foramen ovale and ductus arteriosus, and especially the former, are either 
still patulous, or in such a condition that they may be re-opened under 



SYMPTOMS. 119 

pressure. I cannot explain satisfactorily to myself the sudden supervention, 
in previously healthy young infants, of the alarming dyspnoea, the deep 
discoloration of the skin, and the dangerous or fatal convulsive phenomena 
of atelectasis, by a reference simply to obstructed circulation through the 
collapsed portions of the lungs. On the contrary, I believe that, though 
the first step in the succession of phenomena is, in all probability, an 
obstruction to the passage of the blood from the pulmonary artery into 
the collapsed parts of the lungs, the subsequent and more dangerous 
symptoms, and especially the sudden, almost instantaneous, livid or nearly 
black discoloration of the whole body, and violent convulsions, can be 
accounted for only on the supposition that the overloaded right side of 
the heart empties a part of its venous contents into the left auricle, whence 
they pass into the left ventricle and aorta, and so to the whole body, and to 
the great nervous centres, assisting to produce thereby the deep livid tint 
of the skin, and the general convulsions. 

In this form of atelectasis, the child may have' been born perfectly 
healthy, or merely weaker than usual, or it may have had some difficulty 
in establishing the respiration, which, however, has afterwards been 
effected in the most complete manner. Some days, or even weeks after 
birth, from some cause disturbing the function of respiration, portions of 
the lung may collapse, and give rise to the different symptoms of that 
condition. The most important of these symptoms are difficulty of 
breathing, consisting either in an increased or diminished rate of that 
function, diminution of the muscular power, cyanotic hue of the skin, and 
slight or severe spasmodic phenomena. In one case that occurred to 
myself (see Am. Journ. Med. Sc, Loc. cit.'), a child who had exhibited at 
birth, and for five days after, every appearance of fine health, was observed 
on the sixth day to cry rather violently in the morning. At one o'clock 
in the day he began to moan, and appeared distressed ; at two he ceased to 
moan, became bluish, and seemed to lose his breath. He was placed in 
a bath, in which the blueness passed off, but the breathing continued 
irregular and uneven. He soon became blue again, and breathed slowly 
and irregularly, but had no spasm. At about four o'clock, another 
paroxysm occurred, in which the whole surface became first bluish, and 
then black, while, at the same time, ,the trunk and limbs became 
stiff and rigid under the influence of tonic muscular spasm, and the 
respiration was slow and imperfect. After the attack had lasted for some 
moments, the blueness and spasmodic phenomena disappeared, but the 
child remained in a state of stupefaction. There were two slight parox- 
ysms of convulsive stiffening between this and evening, and later in the 
evening there was still some blueness, with irregular and short respiration. 
During the night the breathing was short and uneven, and attended with 



120 CONGENITAL ATELECTASIS. 

moaning, but on the following day the symptoms had disappeared entirely, 
and there was no return. 

In another case the symptoms of collapse did not appear until the 
twenty-fifth day after birth. The infant had been hearty and strong at 
birth, and had established its respiration fully and completely. Between 
the birth, however, and the time of the attack, circumstances connected 
with the lactation had caused the development of thrush with diarrhoea, 
which had debilitated the child a good deal. On the day of the attack, 
frequent sneezing, with stuffing of the head, and some cough, seemed to 
show the existence of cold, and, on the same day, the child was unfortu- 
nately exposed, owing to the accidental opening of one of the gas-burners, 
to the inhalation of some gas. Late in the evening, a slight whistling 
or stridulous sound was heard in the breathing, the skin became suddenly 
a little bluish, and a slight convulsion followed. During the night there 
were frequent and strong convulsive seizures, always preceded and fol- 
lowed by deep blueness of the mouth, hands, and feet, and it was noticed 
that the least disturbance, as lifting or nursing, or changing the position, 
always brought them on. The next morning the attacks continued, but 
with diminished violence, under the effects of treatment, and they ceased 
after the middle of the day. The color of the skin had now changed ; it 
had become rosy red, instead of pale or blue, and the hands and feet, 
which had been cold, were now warm and natural. There was no return 
after this. 

Diagnosis. — There can be no difficulty in detecting the nature of the 
case, when the imperfect expansion exists from birth, and when the 
physician is present at that event. 

When, however, collapse of the lung-tissue continues after birth, and 
the physician is called upon to determine at the age of some days, weeks, 
or even months, the cause of the feeble health and puny growth of the child, 
or to explain those sudden attacks of collapse in very young infants who 
had previously well established to all appearances the respiration, the 
diagnosis becomes more difficult. In the former class of cases, attention 
to the following points will usually, however, enable us to make a correct 
diagnosis. The previous history is particularly important, since, in all 
such cases, it will be found that the infant was either still-born and 
resuscitated with more or less difficulty, or that it was born weak and 
feeble, and that the respiration had not been established as thoroughly 
and completely as it ought to have been. Dr. Kees states that certainly 
half of the cases of this form, in his own practice, occurred in twins, and 
that they were all born in a more or less completely asphyxiated condi- 
tion. The present symptoms are also very important. The feeble 
appearance of the child, and its puny growth, in connexion with its past 






DIAGNOSIS — PROGNOSIS — TREATMENT. 121 

history, and the absence, as ascertained by careful examination of the 
case, of other morbid conditions to explain the general ill-health, ought 
to direct the attention of the physician to the true nature of the disease : 
and if we add to these considerations the local thoracic symptoms, the 
short, rapid, and imperfect breathing, with, perhaps, the altered move- 
ment of the ribs, the indentation instead of expansion during inspira- 
tion, mentioned above, the absence of fever, and the existence of the 
physical signs of more or less extensive solidification of the pulmonary 
tissue, without those of pneumonia, there will seldom be any difficulty in 
forming a correct diagnosis. 

The cases described under the head of collapse in the early weeks of 
life, may be readily understood from the simple fact that the symptoms 
cannot be satisfactorily explained, by referring them to any other condi- 
tion than that of collapse of portions of the lung, with impeded and 
deranged circulation. 

Prognosis. — The condition of imperfect expansion of the lungs in a 
new-born child, does not necessarily cause it to die immediately or very 
soon after birth. The fate of the child will depend very much upon 
its degree of innate strength and vigor, and upon the kind of hygienic 
conditions to which it may be consigned. When the child is well deve- 
loped, and not enfeebled by any fault in the mother's health during the 
pregnancy, but merely by some momentary condition that has occurred 
during the labor, there is every reason to hope that proper hygienic and 
medical treatment will succed in restoring it to health. The danger is 
greatest in those who continue weak and feeble in spite of the proper 
measures of care and treatment for some days or weeks after birth. I 
have a record of nine examples of this condition in new-born children, 
in whom the symptoms persisted during a period varying between six 
hours and five days, and of these, six lived, while three died in from 
twenty-one hours to three days. 

The prognosis of the second class of cases, those in which collapse 
occurs suddenly in a few days or weeks after birth, and after the appa- 
rently complete establishment of respiration, will vary, of course, with the 
violence of the symptoms. In the two cases that came under my ob- 
servation, recovery took place in spite of the most dangerous and alarming 
symptoms. 

Treatment.' — The treatment of congenital atelectasis resolves itself 
almost solely into the employment of such means as tend to invigorate 
the general health of the child, and to promote the activity of the respi- 
ratory act. In a recent case, one dating from birth, in which the function 
has always been imperfect, and in which there are present great feeble- 
ness, drowsiness, and paleness or blueness, the room in which the infant 



122 CONGENITAL ATELECTASIS. 

is placed should be kept up to a temperature of 70° or 75°, and the child 
should be abundantly covered with warm clothing. Perfect quiet, or at 
least very gentle motion, is very important, and when there is any disposi- 
tion to deep blueness or to convulsive movements, attention to this point is 
essential. It is in such cases, and in those in which these symptoms come 
on a few days or weeks after birth, that the position recommended by my 
father, Dr. C. D. Meigs, for the treatment of cyanosis neonatorum, has 
been found by him so useful. This position is one upon the right side, 
with the head and shoulders raised at an angle of 45°. It is obtained 
by arranging pillows in such a way as to form a plane inclined at that 
angle. Upon this the infant is placed, and orders are given that it is not 
to be moved at all, if possible, or only with the greatest care and gentle- 
ness, for twenty-four or forty-eight hours. There can be no doubt that 
this position and the attendant repose have, in many cases occurring in 
my father's practice, and in several that I have seen myself, been of very 
great use in controlling the symptoms. Its good effects in cyanosis are 
supposed by my father to depend on the fact that the septum auricularum 
becomes, in this position of the body, horizontal, so that the blood in the 
right auricle must rise against gravity in order to pass through the 
foramen ovale, while, at the same time, the valve of that opening is dis- 
posed to fall down by its own weight, and close the foramen, and is, 
moreover, pressed downwards by any blood that may enter the left auricle 
from the pulmonary veins. This explanation will apply, of course, only 
to those cases of atelectasis accompanied by very extensive and deep 
blueness or purple color of the surface, in which we may suppose that so 
much of the pulmonary tissue is solidified, as to produce a degree of ob- 
struction to the passage of blood from the right side of the heart into the 
lungs, sufficient to overload the right ventricle and auricle, until the 
latter pours a portion of its contents into the left auricle, thus causing 
admixture of the two kinds of blood. In a large majority of the cases 
of atelectasis, however, this explanation of the benefit resulting from the 
treatment referred to, cannot be received, as there is no reason to suppose 
that in them the slight cyanotic symptoms present indicate anything 
more than the existence of a moderate degree of congestion of the right 
side of the heart, unattended by any escape of blood from the right into 
the left auricle. In such cases the position on the right side is useful, 
because it is the one most favorable to a full and easy performance of the 
respiratory and circulatory functions. It leaves the left side free and 
unembarrassed, so that the heart can act with the greatest possible free- 
dom, while the partial elevation of the head and shoulders renders the 
movements of the chest more easy and complete than when the body is 
lying on a horizontal surface. The perfect quiescence which constitutes a 



COLLAPSE OP THE LUNG. 123 

part of the treatment is also very important, as in many recent and parti- 
cularly in cyanotic cases, the symptoms are greatly aggravated, and convul- 
sive attacks often brought on by moving the child, especially if this be done 
suddenly or rudely. 

Perhaps the most important point of all in the treatment of this affec- 
tion, especially when the symptoms tend to become persistent, is the 
mode of nutrition of the child. If possible, the infant should always 
have a good breast of milk, and if unable to suck, the milk ought to be 
drawn and fed to the child from a spoon. About two or three teaspoon- 
fuls may be given at first every half hour or hour, and the quantity gradu- 
ally increased until the child gains strength enough to be put to breast. If 
breast-milk cannot be procured, cow's milk and water may be substituted, 
in the proportion of one part of the former to two or three of the latter. 
The only medicines to be given are, at first, while the child is still very 
young and weak, mild stimulants, of which the best, in my opinion, is 
fine old brandy. Of this about five drops may be given each time that 
the milk is taken ; or, we may make use of from three to five drop doses 
of the aromatic spirits of hartshorn, or of proper quantities of wine-whey. 

When the symptoms of congenital atelectasis tend to persist for several 
weeks or months, and when we first see the patient some time after birth, 
the chief points to be attended to in the treatment are, as before, the mode 
of nutrition, which ought to be by nursing, and the use of gentle stimu- 
lants and tonics. Brandy, wine, or Hexham's tincture of bark, are the 
best stimulants, whilst quinine, in the dose of a quarter or half a grain 
three times a day, extract of cinchona, in the dose of from one to three 
or four grains, three times a day, or iron in the form of Quevenne's powder, 
or in that of the iodide, are the best tonics. 

COLLAPSE OF THE LUNG OR POST-NATAL ATELECTASIS. 

General Remarks. — By collapse of the lung is meant the return of 
that organ to its foetal or unexpanded state. It is in fact a condition of 
atelectasis or imperfect expansion of its vesicular structure. The terms 
collapse or post-natal atelectasis are employed to contra-distinguish it from 
congenital atelectasis, the former being applied to imperfect expansion as 
it occurs in lung-tissue after previous expansion, and the latter, as stated 
in the preceding article, to the same condition as it exists in children who 
have never expanded certain portions of the pulmonary substance. 

The true nature of collapse of the lung was never understood, and its 
great practical importance never appreciated, until since the year 1844, 
when MM. Legendre and Bailly published, in the Archives Generates de 
Medecine their researches on the subject. Since then various observers 



124 COLLAPSE OF THE LUNG. 

have repeated the investigations of those gentlemen, and thrown new 
light upon the matter. Among the most important of the later writers 
on this subject, I may mention Dr. Charles West, of London, MM. 
Hardy et Behier, of Paris, and Dr. W. T. Gairdner, of Edinburgh. 

This new discovery in pathology is one of very great value, not merely 
because it renders our knowledge of the morbid conditions of the lungs 
more exact and philosophical than it ever was previously, but because it 
explains certain anatomical changes in the pulmonary structures, often be- 
fore noticed and described, but never satisfactorily accounted for ; and still 
more, because it points to methods of treatment much more rational and 
much more successful than those employed under the influence of diffe- 
rent ideas as to the nature of the lesions alluded to. The most important 
result that has issued out of the new views advanced, is the disclosure of 
the fact that several lesions met with after death, which were formerly 
thought to depend on inflammation of the affected tissue, are in reality, 
the consequences of simple collapse or obliteration of the vesicular struc- 
ture of the lung, and not at all of inflammation, as was at one time sup- 
posed. The lesions alluded to are those which have been hitherto described 
under the names of lobular pneumonia and carnification. 

The peculiar character of the lesions met with in many of the supposed 
cases of pneumonia, had often drawn attention and been commented upon, 
before their real nature came to be understood. The points of difference 
between these alterations and those of true pneumonia, were particularly 
noticed by MM. Denis, De La Berge, Kufz, Killiet and Barthez, and 
Dr. West. In fact, M. Rufz, and MM. Rilliet and Barthez, both ap- 
proached very near the truth in regard to these lesions, each comparing 
them, but the former at an earlier period than the latter, to the condition 
of the lung of a foetus that has never breathed. The latter writers, in their 
article on pneumonia, have described a condition of the lung which differed 
so much from ordinary pneumonia, as to create a great difficulty in their 
minds as to its true nature, and to it they applied the term carnification. 
They were on the very verge of detecting its real character ; they did in 
fact suggest its real character, but were so possessed with the idea that it 
must be the result of some inflammatory action, as to neglect to pursue 
their own suggestion, but endeavored to explain the condition on the 
ground that it was " one mode of termination of pneumonia or else chronic 
pneumonia/' The following passage, quoted from their work (T. 1, p. 
74), will show how closely they approached the truth : " The first idea 
that enters the mind on examining this tissue (carnification), is, that it 
resembles the lung of a foetus that has not breathed j we should feel in- 
clined to say that the pulmonary vesicles had not yet been dilated under 
the influence of the thoracic expansion, and had not, therefore, admitted 



GENERAL REMARKS. 125 

air into their interior, or, rather, it would seem as though they had been 
obliterated by some attack of disease, perhaps inflammation, without, 
however, remaining engorged, and after having lost the power of dila- 
tation/' 

But it is not only the condition of the lung, called by Rilliet and 
Barthez carnification, that has been shown to consist, not in inflammation, 
but in a collapse of the pulmonary tissue. A much more important conse- 
quence of the recent researches has been the discovery that in a very large 
majority of cases the so-called lobular pneumonia, generalized lobular 
pneumonia, and pseudo-lobar pneumonia of different writers, are also the 
results of collapse of the lung, variously combined with bronchitic inflam- 
mation and congestion of the pulmonary tissue. The latter discovery has 
lessened very much the importance of pneumonia as a disease of early life, 
while it has augmented in the same proportion, that of bronchitis, for it 
has shown that a very large number of cases, formerly regarded as true 
inflammation of the parenchyma of the lung, are in fact cases of bron- 
chitis combined with collapse of the tissue of the organ. 

Now that the nature of collapse of the lung, in connexion with bron- 
chitis, and sometimes, also, with true pneumonic inflammation, has been 
made known, a number of symptoms occurring in the pulmonary affections 
of children, which were formerly obscure and irregular, have become easily 
explicable. It had been often observed that many of the supposed pneu- 
monias of children did not present the same symptoms, pursue the same 
course, nor require the same treatment as the pneumonia of adults, or as 
some cases of the disease in children. In a great many of the supposed 
cases there was an unusually large amount of bronchial inflammation, the 
general symptoms were much less acute than was to be expected in a 
parenchymatous inflammation, and what was most singular of all, the 
physical signs of solidification of the lungs were very variable and uncer- 
tain, there being present on one day the signs of simple bronchitis, while 
on the same day or the following, and over the same region of the thorax, 
these would be associated with or masked by the signs of induration of 
the lung ; and again in a day or two, the symptoms indicative of condensa- 
tion might disappear, to be succeeded yet again by those of simple 
bronchial inflammation. The effects of treatment seemed also to point 
clearly to a radical difference between the lobular or bronchio-pneumonia 
of children, and the acute phlegmasial disease of adults. It was found, in 
fact, that depletory measures were seldom borne well in the lobular pneu- 
monia of children, while in the pneumonia of the adult, and in some acute 
cases occurring in early life, which presented the same general symptoms 
and the same physical signs as adult-pneumonia, antiphlogistics, as is well 
known, were the most successful remedies that could be made use of. 



126 COLLAPSE OF THE LUNG. 

Anatomical Lesions. — Collapse of the lung (post-natal), occurs in 
two different forms, the diffused, and the limited or lobular. The only 
difference between the two forms is in the number of lobules affected, and 
their mode of distribution. In the diffused variety, a large number of 
adjoining lobules collapse, and give a condensed and solid appearance to 
larger or smaller portions of the lung, most frequently to the edges, 
merely, of one of the lobes, but at others to the greater part or the whole 
of a lobe, or even the major part of a lung. In the lobular variety, on 
the contrary, single lobules or clusters of lobules become collapsed in dif- 
ferent parts of a lobe or lung, and the affected portions take the form of 
irregular, hardened patches or tumors, situated upon the surface, or dis- 
seminated through the interior of the pulmonary texture. In the former 
kind of collapse, the appearance of the altered portion of the lung is some- 
what that of lobar pneumonia, and it is to these cases that the terms gene- 
ralized-lobular, pseudo-lobar, carnification, and splenization, have been 
applied j while in the latter kind, the isolated, and distinct condensed por- 
tions, have been described by the term lobular pneumonia. 

The peculiar, or fundamental characters of collapsed pulmonary tissue, 
are the same in both varieties. I will mention them as succinctly as 
possible, and then compare them with those of pneumonia, for the reason 
that it is with the lesions of that disease that those of collapse have been 
hitherto confounded. 

Collapsed lung is generally of a dark violet color, but it may be much 
darker in tint, and even black, when it is much engorged with blood. Its 
consistence is always changed ; the condensation may amount merely to 
slight hardening, with a diminution of the crepitation, or it may be very 
dense with an entire absence of crepitation, in which case portions thrown 
into water sink rapidly. Though more or less hardened, the tissue still re- 
tains a certain degree of flaccidity and suppleness. When cut into, the 
surface is seen to be smooth and uniform, having somewhat the appear- 
ance of muscle, and presenting no granulations. Pressure or scraping 
cause the exudation of more or less semi-transparent bloody serosity. 
Close examination shows that the organic elements of the tissue, the 
vessels, bronchia, cellular tissue, etc., can still be distinctly traced. 
Lastly, inflation of the lung distends the condensed parts, and gives to 
them again, more or less completely, their natural physiological characters. 

The alterations just described resemble so much those caused by in- 
flammation of the parenchyma of the lung, and have been so long con- 
founded with them, that it will be well to compare the two conditions, in 
order that the difference between them may be clearly perceptible. 

The color is different in the two alterations, being in collapse purple 
or livid, and in pneumonia brownish-red or fallow-red. In pneumonia 



ANATOMICAL LESIONS. 127 

the pleura covering the hepatized portions is often covered with false mem- 
brane, showing thereby the inflammatory nature of the disease : in col- 
lapse this is rarely the case, and only when there is some accidental con- 
comitant pneumonia. The density of the lung in the two conditions is of 
a different kind : in pneumonia it is hard to the touch, and unyielding ; in 
collapse it always retains a certain degree of flaccidity and softness, like 
that of muscular tissue. In pneumonia, the diseased part is turgid and 
swelled, so that it projects above the common level of the surrounding 
surface ; in collapse, on the contrary, it is shrunken and depressed below 
the neighboring parts. In pneumonia the effects of the inflammatory pro- 
cess on the tissues is very strongly marked, and produces changes in them 
very different from those occasioned by mere collapse. In that disease the 
cohesive properties of the pulmonary structure are very much lessened, so 
that the inflamed parts are readily penetrated by the finger, and are easily 
torn, whilst in collapse the diseased part is as firm and resisting, or even 
more so, than in health. In the true hepatization of pneumonia, a cut 
surface always presents a granular aspect, while in collapse, on the con- 
trary, it is smooth and even. On scraping a cut surface it is found that, 
in the former alteration, a plastic, fibrinous matter of a yellowish, orange, 
or gray color, comes off on the knife, while in collapse only some semi- 
transparent bloody serosity is scraped off. In the former, the anatomical 
arrangements of the lobules cannot be seen, as the inflammation attacks 
indifferently the lobules themselves, the inter-lobular septa, and parts of 
neighboring lobules ; but in the latter, the alteration can always be seen 
to be more or less regularly confined to the lobules, the cellular interstices 
between the lobules remaining more or less apparent; so that in pneumonia 
the alteration is not bounded at all by the outlines of the lobules, while 
in collapse the alteration always affects, more or less, the lobular form. 
To conclude, the effects of inflation are altogether different in the two con- 
ditions. M. Legendre (Recherches Anatom.-Path. et Clin, sur quelques 
Mai. de V Enfance, p. 164), states that air can never be made to penetrate 
by inflation into a completely hepatized lung. Neither in hepatization of 
the lobar form, nor in true partial hepatization, has he ever been able, even 
with the utmost effort, to push air into the midst of the inflamed tissues. 
After repeated trials, the tissue remained compact and friable, and sank 
as rapidly as before when thrown into water. In the foetal state, on the 
contrary, the slightest effort sufficed to fill and distend the collapsed air- 
cells, and to give to the altered portion its natural appearance, excepting 
that it became more red in consequence of the oxygenation of blood con- 
tained in the capillaries. Dr. G-airdner (Pathol. Anat. of Bronchitis, etc., 
Edinburgh, 1850, p. 13-14), remarks that though this test "is very useful 
in demonstrating the nature of the lesion, in a favorable case, to one not 



128 COLLAPSE OP THE LUNG. 

familiar with its character, I do not believe it to be applicable to the de- 
termination of the presence or absence of pneumonia in those mixed cases 
in which alone there is any difficulty/' He has observed, in fact, that 
partially pneumonic lung may be inflated when the affection is recent and 
combined, as it frequently is, with bronchitic collapse, while in the latter 
lesion in its purest forms, complete inflation is often very difficult or impos- 
sible, after the collapsed state has been of some duration. 

The part of the lung in which collapse is most frequently met with, 
depends somewhat on the form of the alteration. In the diffused variety, 
it may affect a more or less considerable portion of either or both lungs, 
but is most common at their posterior part. The lobular variety is most 
common on the anterior edges, but may, like the diffused, occur in any 
other part. As a general rule, the alteration is most frequent at the 
periphery of the organ, where its edges are thin, as along the margins of 
the lobes, in the languette of the upper lobes, and at the bases of both 
lungs. The parts just named are those most distant from the primary 
air-passages ; they are those in whicb the inspired air would arrive last, 
and with the least force of impulsion. 

Causes. — It has been generally acknowledged that there are two prin- 
cipal causes by which to explain the production of collapse of the lung. 
These are the presence of an obstruction in the bronchia, which hinders 
the ready transmission of the inspired air, and a deficient power of inspi- 
ration. To these Dr. Gairdner adds another, — the inability to cough and 
expectorate, and thus remove the obstructing mucus. 

The most important of the above-mentioned causes is evidently the 
deficient respiratory power, since this is noticed and insisted upon by all 
observers. It has been found, in fact, that collapse seldom occurs to any 
considerable extent except in children who are exhausted and debilitated. 
The debility may be congenital, it may be the result of wearing diseases, 
as diarrhoea, hooping-cough, measles, typhoid fever, &c, or it may depend 
on exposure to unwholesome and enfeebling hygienic conditions. It is 
easy to understand that a child who is either born weak and feeble, or 
who becomes so in after years from any of the causes just alluded to, 
must lose, with the general decay of the strength of the body, some. por- 
tion of the muscular power by which alone a complete and efficient dila- 
tation of the thoracic cavity can be accomplished, and that, when this is 
the case, the inspirations must be short and imperfect, and that portions 
of the lung most distant from the primary air-passages, not being reached 
by the inspired air, will remain in an unexpanded or collapsed state. 
And if we add to this state of feeble respiratory power, the presence of 
opposing secretions in the air-tubes, whether these be the consequence of 
bronchial inflammation, as they are in the immense majority of cases, or, 



CAUSES. 129 

as Dr. Gairdner suggests they may sometimes be, the mere natural secre- 
tion of these tubes, accumulated for the want of power to throw them off, 
it becomes abundantly easy to comprehend the mode of production of 
collapse in at least some of the examples. 

Whether a simple deficiency of inspiratory force alone, without ob- 
structing mucus in the bronchia, will give rise to collapse, is a somewhat 
mooted point. Dr. West agrees with MM. Legendre and Dailly, in the 
opinion that it is often due to the inspiratory power having been inade- 
quate to overcome that natural elasticity of the lung which opposes a full 
dilatation of the organ. Dr. Gairdner (Loc. cit., p. 33) cannot " see 
reason to believe with Dr. West, that mere debility, apart from any ob- 
struction in the tubes, is a sufficient cause for collapse in the child/' 
He remarks, and with strong show of reason, that the very fact of the 
lesion being usually more or less lobular, or partial in its distribution, 
appears to indicate special circumstances of a local kind, as having a 
marked influence on the production of this affection. What is of most 
consequence, however, to the working physician, as an important prac- 
tical truth, is the fact stated by several observers, and adverted to by Dr. 
G-airdner himself, that in some cases no signs whatever of obstructive 
bronchitis or of bronchial accumulation can be discovered during life. 
Before leaving this point, I desire to call attention to the opinion of Hasse 
(Pathol Anat.y Syd. Soc. Ed. y p. 253), that, though this partial intro- 
duction of air might be deemed at variance with the laws of respiration, 
inasmuch as the atmospheric pressure must necessarily distend the entire 
lung equally, not to the exclusion of a lobe, and still less, to that of a 
lobule, the objection falls to the ground when it is considered that the 
operation of these laws is the result of previous muscular action. He 
refers to the fact that in pleurisy one-half of the thorax, and in partial 
pleurisy certain portions of that cavity, do not share at all in the move- 
ments of the remainder. " We need, therefore," he says, u be at no loss 
to understand how defective breathing may originate in a merely partial 
activity of the intercostal or other respiratory muscles." 

Dr. Gairdner, as already stated, considers as one of the causes of 
collapse, an inability to cough and expectorate, and thus to remove the 
obstructing mucus. The views which he expresses on this point are very 
interesting, and also, I think, very important. He states that Laennec 
supposed the expiratory force of respiration to be weaker than the inspira- 
tory, while in fact the experiments of Hutchinson and Mendelsohn, to which 
he refers, prove that though ordinary inspiration is more of a muscular 
act than ordinary expiration, yet the residual effective force for over- 
coming adventitious obstruction is very considerably greater in expiration. 
" The forced or muscular expiratory act is, in fact, about one-third more 

9 



130 COLLAPSE OF THE LUNG. 

powerful, as measured by its effect upon a pressure-gauge, than the 
extreme force of inspiration ; and it is this force which is thrown into 
action when obstruction in the tubes is to be overcome. " In the act of 
coughing, the air in the vesicles is brought to bear upon the obstructing 
substance within the bronchia, at a maximum amount of outward pressure, 
and with the additional mechanical advantage of a sudden impulse, so that 
the practical efficiency of the expiration in forcing air through obstructions 
must be far greater than that of inspiration. It is clear, therefore, that, 
if the secretions in the air-passages be so abundant or so viscid as to inter- 
fere materially with the entrance and exit of air, they must necessarily 
occasion collapse, either partial or total, of the parts beyond them, since 
not only does the air enter with difficulty, but being expelled with greater 
force and in larger quantity than it can be drawn in, the amount remain- 
ing in the vesicular structure must gradually diminish. This effect of 
obstruction will be still more remarkable when the muscular force of 
respiration is diminished by debility of the patients, for then the inability 
of the inspiratory act to replace the air driven out by expiration, will be 
yet more marked than when the muscular powers of the body retain their 
full force. 

There is still another mechanical condition which tends to produce 
collapse from obstruction, to which Dr. Gairdner refers. This condition 
is to be found in the form of the bronchial tubes. These tubes are a 
series of gradually diminishing cylinders, and if a plug of any kind, but 
especially one closely adapted to the shape of the cylinders, and possess- 
ing considerable tenacity, be lodged in any portion of such a cylinder, 
it will move with much more difficulty towards the smaller end, and in 
doing so will close up the tapering tube much more tightly against the 
passage of air, than when moved in the opposite direction into a wider 
space. From this arrangement of the parts, it will happen that at every 
expiration a portion of air will be expelled, which, in inspiration, is not 
restored, owing in part to the comparative weakness of the inspiratory 
force, and in part to the valvular action of the plug. " If cough super- 
vene, the plug may be entirely dislodged from its position, or expecto- 
rated, the air, of course, returning freely into the obstructed part ; but 
if the expiratory force is only sufficient slightly to displace the plug, 
so as to allow of the outward passage of air, the inspiration will again 
bring it back to its former position, and the repetition of this process 
must, after a time, end in perfect collapse of the portion of lung usually 
fed with air by the obstructed bronchus." 

I have been thus particular in my consideration of the causes of col- 
lapse, because I am convinced, from personal observation, that it is a 
subject of very great importance in practice. Many times, in the last 



SYMPTOMS. 131 

few years, I have met with cases of bronchitis, either primary or secon- 
dary, in weak and debilitated children, in which the general and local 
symptoms have pointed clearly to the existence of collapse of the lung, 
and in which, moreover, the good effects of a sustaining and even stimu- 
lating treatment have shown the great utility of an acquaintance with the 
nature of this affection, and its proper remedies. 

Symptoms. — As collapse of the lung occurs almost always in connexion 
with bronchitis, though sometimes, also, after, or concomitantly with 
pneumonia, it is clear that the symptoms which reveal its existence must 
be mingled, in a greater or less degree, with those of the two diseases 
just named. It is true, nevertheless, that it sometimes occurs unasso- 
ciated with more than slight evidences of any other disease of the lung. 
Cases of the latter kind have been usually observed only in children dying 
in states of utter exhaustion, in whom the muscular power of respiration has 
been so completely debilitated, as to prevent a dilatation of the thoracic 
cavity sufficient to carry the air into the deeper parts of the lung. In such 
instances, the symptoms of collapse do not show themselves until a 
very short time before death, and they consist in the sudden appearance 
of very rapid and oppressed breathing, with little or no cough, in more 
or less extensive dulness on percussion over different parts of the chest, 
but most commonly the inferior dorsal regions, and in feeble or suppressed 
respiratory murmur, or more commonly a distant and imperfect bronchial 
respiration. In some cases, however, in which there is very little bron- 
chial complication, as shown by the rarity and small amount of the 
catarrhal rales, the symptoms of collapse continue with more or less 
irregularity, as to situation and extent, for periods of several weeks, or 
even months. But here, also, as in the cases previously referred to, the 
general debility and low health of the child are strongly marked, and are, 
with slight variations, persistent. As an instance of this kind of collapse, 
I may cite the following case, which occurred in my own practice. 

A boy, between three and four months old, who, at birth, and up to 
the time of this attack, had presented every appearance of strong and 
vigorous health, was seized, on the 3d of October, 1849, with symptoms 
of a somewhat irregular and anomalous character, but which I soon 
suspected to be the signs of an intermittent fever. I was induced in part 
to make this diagnosis, from the fact of my having attended the mother 
during her gestation of this child, in a severe attack of intermittent fever. 
At the beginning of the sicknesss, there was some little coryza, but no 
cough whatever. On the 3d October, after the coryza had lasted for a 
few days, he became worse, and I was sent for. During the six days 
following this, he had one or two attacks each day of coldness of the 
extremities, followed by violent fever, and ending sometimes with perspi- 



132 COLLAPSE OF THE LUNG. 

ration. He was exceedingly fretful, screamed a great deal, was at times 
drowsy and dull, and vomited occasionally. The stools were regular and 
perfectly natural. The breathing was rapid and short nearly all the time, 
but there was no cough whatever. On the seventh day, the respiration 
was 100 by the watch, and irregular. The child was pale, weak, drowsy, 
and entirely without cough. Percussion revealed nothing, and no rales 
could be heard. On the eighth day, the breathing was 96, and a slight, 
dry cough was heard two or three times. When roused up, the intelli- 
gence of the child seemed perfect. On the ninth day, the breathing 
was 63, and the pulse 120. There was rather more cough, though still 
very little, and there was a slight return of the coryza, of which there 
had been none for several days before. Neither auscultation nor per- 
cussion revealed any decided change in the lungs. On the eleventh day, 
the paroxysms of chilliness, followed by fever, were still noticeable, 
though there was no clearly marked periodicity in the returns. When 
without fever the breathing was 54 j during the fever it was 67. Aus- 
cultation revealed nothing decided. Percussion showed dulness beneath 
the right clavicle. By the seventeenth day, the intermittent nature of 
the disorder was more decidedly marked, and under a few doses of qui- 
nine the symptoms had improved, so that the breathing was down to 
30 during sleep. The cough was a little more frequent, though still 
very slight, and it was loose. The coryza, also, was more considerable, 
the nasal discharge being quite abundant. 

After this the case went on badly, owing, I think, in great measure, to 
the circumstance of the quinine being abandoned in consequence of the 
opposition made by the parents to its administration, — an opposition 
which I allowed to influence me more than was proper. During Novem- 
ber and December, the child remained weak, pale, languid, and with 
uncertain appetite, sometimes refusing the breast for a whole day at a time. 
The quinine was suspended at first on account of the great improvement 
which had taken place in the symptoms, and though resumed afterwards, 
was given in such small quantities, and for so short a time, for the reasons 
just mentioned, as to be of no service. In December the child was very 
ill. It looked very badly, having a pale, waxy face, and a dull, languid 
expression, though without any want of intelligence ) it emaciated mode- 
rately, and had occasional vomiting; the stools were natural. At this 
time also, it took the mother's breast with some difficulty, and refused 
artificial food altogether. Occasionally during this month, there was 
observed a slight blueness around the mouth, and also about the hands 
and feet. Late in the month it was attacked with thrush in a slight de- 
gree, which lasted several days. In the first week of January, finding 



SYMPTOMS. 133 

that it was fast sinking from refusing the mother's breast and artificial 
food, a wet-nurse was procured, and for a few days it seemed to improve 
a little, but this did not last. It grew weaker and thinner, the thrush 
returned, it had now a good deal of loose cough, the abdomen became 
somewhat contracted and felt hard and doughy, and the breathing was 
very rapid, though not greatly oppressed. The child died at last on the 
26th of January, having, for ten days before that event, looked wretchedly 
languid and haggard, and having presented for three days before, slight 
diarrhoea, loose, frequent cough, entire loss of appetite, thrush, drowsiness, 
and finally coma. 

At the autopsy there were found some fibrinous exudation, and a few ad- 
hesions over the lower half of the left lung. The lower two-thirds of the 
left, and the lower half of the right lung were dark-colored, more dense than 
usual, not friable, and exhibited no granulations on a cut surface. These 
portions were in fact collapsed. The upper lobes were spongy, crepitant, 
and healthy. Not a tubercle was found. The foramen ovale presented 
an oval-shaped opening, of the size of a goose-quill. The abdominal organs 
were healthy. 

When, as indeed, most usually happens, collapse occurs in the course 
of bronchitis, it is associated of course with the symptoms of that disease. 
The bronchitic symptoms have lasted in their usual form for several 
days, having been marked by sonorous, sibilant, and subcrepitant rales, 
when suddenly, or in the space of a few hours, the breathing becomes 
much worse, the pulse rises in frequency but becomes small and feeble, 
and certain changes take place in the physical signs which are very im- 
portant. The subcrepitant rale continues to be heard, but it is associated 
now with prolonged expiration, and a little later with bronchial respira- 
tion, which, however, is of a different kind from the bronchial respiration 
of pneumonia, being distant and smothered, instead of near and metallic, 
as in that disease. The percussion becomes at the same time, dull and 
obscure, but never, scarcely, to the same extent as in pneumonia. The 
general symptoms are those of exhaustion, rather than of high reaction. 
The surface is pale or slightly bluish, the skin is either natural, slightly 
warmer than usual, or coolish, the strength is very much reduced, and the 
child appears more seriously ill, and particularly more oppressed often 
than the amount of bronchitis present would seem to explain. 

As an example of collapse occurring in the course of bronchitis, I will 
give the following case. A girl between two and three months old, healthy 
when born and up to the time of the sickness, saving that she was rather 
paler and smaller than most robust infants, was seized with coryza and 
slight cough, and after a few days with the symptoms of a mild bronchitis. 
For two days there was frequent cough, some little fever, quick but not 



134 COLLAPSE OF THE LUNG. 

oppressed breathing, occasional sibilant and mucous rale, perfect ability to 
nurse, and very moderate restlessness or fretfulness. On the third day, 
without any apparent reason, the symptoms became suddenly very 
alarming. The breathing became extremely rapid and most violently 
oppressed, so that the movements of the chest at each respiration were 
heaving and laborious, the shoulders being lifted high at each inspiration, 
the outer angles of the mouth drawn downwards, and the alae nasi widely 
dilated. There were at the same time abundant subcrepitant intermingled 
with dry rales over the dorsum of the chest. In this case, moreover, the 
symptom mentioned by Dr. Rees, was very well marked. The base of 
the chest was driven inwards at each inspiration, producing at that point 
an evident constriction, whilst the upper parts were lifted high in the 
effort to carry on the respiration. The cough was frequent and racking, 
and occurred in paroxysms. The child was still and quiet, pale, had a 
haggard and exhausted look, was unable to nurse at all, and its surface was 
cool and white, especially that of the extremities. These symptoms con- 
tinued with very little modification for twenty-four hours, when, under the 
use of brandy, administered every hour in milk drawn from the mother, 
of the spirits of Mindererus and paregoric, perfect quiet, and the assi- 
duous employment of mild revellents, they began to moderate, and at 
the end of another twenty-four hours, the constriction at the base of the 
thorax during inspiration had disappeared, the breathing was easy and 
gentle, the extremities had become warm, the child nursed eagerly and 
abundantly, and with the exception of a slight catarrh, which lasted a few 
days longer, it was well. 

Collapse depending on bronchitic inflammation, in debilitated children, 
may sometimes last a considerable length of time. In one case, indeed, 
that I saw a few years since, and of which I published an account (see 
Am. Journ. Med. Sci. for January, 1852, p. 98), the symptoms, owing 
probably to the fact that the bronchitis causing the collapse was an ac- 
companiment of hooping-cough, continued with slight variations in degree, 
for a period of about three months, after which the child entirely reco- 
vered. 

Diagnosis. — The diagnosis of collapse of the lung must always be 
more or less uncertain where it is of the lobular form, for the reason that 
the collapsed lobules being disseminated irregularly through the pulmonary 
tissue, afford no physical sign by which we can detect their condition. The 
presence of this form ought, however, to be suspected whenever, in a 
chronic disease, and especially in the course of a catarrhal attack occurring 
in a feeble and debilitated child, the breathing becomes excessively quick 
and labored, the skin pale and coolish, when the base of the thorax pre- 
sents a depression instead of expansion during inspiration, and especially, 



DIAGNOSIS — PROGNOSIS. 135 

when these symptoms occur without there being a sufficiently severe and 
extensive bronchitis to explain their existence. 

In cases of collapse affecting a considerable, or the greater part of a 
lobe, the diagnosis, though still perhaps rather uncertain from the com- 
paratively recent date of the researches into this condition, is much more 
clear and positive than in the lobular form. In the latter form we are 
obliged to depend, indeed, almost exclusively upon the rational symptoms, 
the physical signs being either very slight or entirely null. In collapse 
of considerable portions of the lung-tissue, we have, on the contrary, some 
very useful physical signs. These are : the existence of dulness, greater 
or less, on percussion ; feeble respiratory murmur ; prolonged expiratory 
sound, and sometimes bronchial respiration ; which, when they occur in 
connexion with, and in the course of bronchitis, are usually quite suffi- 
cient to render the diagnosis easy. 

The only diseases with which collapse presenting the physical signs just 
mentioned could be confounded, are pneumonia and pleurisy. From both 
of these it is usually distinguishable by the absence in collapse, or the 
slight severity, of the reactional symptoms, by the paleness or blueness 
and coolness of the surface, by the absence of acute pain, by the greater 
severity in collapse of the bronchitic symptoms, and by the fact that it 
rarely occurs except in enfeebled, broken-down subjects, or in those labor- 
ing under severe bronchitis. The character of the physical signs, more- 
over, is different. Though we have dulness on percussion in collapse, it 
is not so absolute as that either of pleurisy with large effusion, or that of 
confirmed pneumonia. The bronchial respiration, too, is in collapse, dif- 
ferent from that of pneumonia. It is muffled and distant, instead of 
being clear, metallic, and close under the ear, as in pneumonia. It is in 
fact more like that of pleurisy. It is heard, too, much more in the expi- 
ration than in inspiration, while in the latter is still heard, unlike either 
pneumonia or pleurisy, an abundant subcrepitant rale. To add to these 
differences, it is proper to say that in most cases of pneumonia and pleurisy, 
the course of the disease is much more regular, and the special symptoms 
so well marked as to leave no doubt as to the real nature of the attack. 

Prognosis. — The prognosis of collapse must depend, in great mea- 
sure, on two circumstances, — the amount of bronchitis which accompanies 
it, and the constitutional state of the child. "When it occurs during the 
course of extensive bronchitis, as shown by a great abundance and extent 
of the bronchitic rales, it must add greatly to the danger of that disease ; 
and if, at the same time, the child be weak and debilitated, either from 
causes long previously in action, or from the severity of the present attack, 
the risk to life is very great indeed. Collapse is dangerous also, but far 
from necessarily fatal, in subjects in whom its chief cause has been simple 



136 COLLAPSE OP THE LUNG. 



debility. The possibility and the probability of recovery will depend on 
the hygienic conditions to which the child is exposed, the degree of vital 
strength it is likely to inherit from its parents, the extent of the collapse 
as indicated by the severity of the thoracic symptoms, both rational and 
physical, and the effects of treatment. When the subject can be placed 
under favorable hygienic conditions, when it has inherited from its parents 
a good and vigorous hold on life, and when the symptoms of collapse are 
not very violent, a proper and rational treatment will in all probability 
save it, while, under opposite circumstances, the chance of recovery would 
be very small, if there were any. 

Treatment. — The treatment of collapse, or post-natal atelectasis, must 
vary somewhat in different cases. One general rule will apply, however, 
to all j this is to employ a sustaining and strengthening system of medica- 
tion, to the exclusion of all exhausting means. 

In cases which are entirely, or almost entirely, independent of bron- 
chitis, the most important measures to be attended to are the regulation of 
the temperature in which the child is kept, of the clothing, and of the diet, 
the use of mild stimulants and of tonics, and the external employment of 
revellents. The child ought to be kept in a warm, even temperature, one 
from 70° to 75° ; it should be clothed in soft flannels, and its diet ought to 
be nourishing and strengthening. If at the breast, we should be sure that 
the milk is of a good quality, and that the nurse has an abundant flow. If 
weaned recently, it ought to have, if possible, a wet-nurse, and so also if it 
be supposed that the mother has too little milk, or that this is not perfectly 
healthy. If permanently weaned, the diet should be so arranged as to give 
to the child what is at the same time easy of digestion and nutritious. In a 
severe case, coming on suddenly, the most suitable internal remedies are 
brandy, in small doses, frequently repeated, Huxham's tincture of bark, 
the spiritus Mindereri or the aromatic spirits of hartshorn, and small doses 
of quinine or extract of cinchona. In slower and more chronic cases, we 
must depend on a well-selected and nutritious diet (and food ought to be 
given almost by force, or at least it should be urged strongly on the child), 
on warm clothing, and on the use internally of brandy, quinine, the citrate 
of iron and quinine, pure metallic iron, the iodide of iron, Huxham's 
tincture of bark, or some such remedy. In sudden cases, the best revel- 
lents are the following : mustard, weakened by admixture of flour or 
Indian meal, and applied once in three or four hours ; a plaster made of 
suet or simple cerate grated over with nutmeg; or liniments composed 
of ammonia, spirits of turpentine, or oil of amber, mixed with sweet oil. 
In chronic cases, the Burgundy pitch, or compound Galbanum plaster, 
made somewhat weaker than those used for adults, should be applied over 



;al 

Sft 



TREATMENT. 137 

the front and back of the chest, or we may rub the thorax twice a day with 
any ordinary ammonia liniment, made, if necessary, rather more irritating 
than usual by the addition of some oil of monarda. The daily use of a 
gentle emetic of ipecacuanha has been recommended, and supposed to 
prove useful, by emptying the bronchia of their secretions, and also by 
the fact that its operation induces several deep inspirations, and in that 
mode promotes the better performance of the respiratory act. I have 
never employed the emetic except in cases accompanied with a good 
deal of bronchitis and consequent accumulation of mucus in the air-tubes, 
and not then when the prostration was very great. In fact, the operation 
of any emetic is sometimes productive of so much exhaustion of the 
strength, as to cause me to hesitate in prescribing any substance of that 
class; though I can fully understand that the act of vomiting, if not fol- 
lowed by too much prostration, could scarcely fail to prove beneficial in 
collapse, by the strong efforts at breathing which it gives rise to, and also 
by the succussions it must impart to the lungs through the medium of the 
diaphragm. 

In cases of collapse occurring in the course of, or towards the termina- 
tion of severe bronchitis, the treatment must resemble a good deal that 
which I have just described as proper for the same condition, when it 
exists unassociated, or associated only to a slight extent, with that disease. 
When the symptoms of imperfect expansion appear towards the termina- 
tion of, or after the patient has partially recovered from bronchitis, and when 
of course the strength is more or less reduced by the severity of the pre- 
vious acute sickness, and also perhaps by the necessary measures of 
treatment, the case ought to be managed very much in the same way as 
has just been recommended for those in which the collapse was caused 
chiefly by exhaustion, and less by the presence of obstructing secretions, 
in the bronchia. Nourishing but very light and digestible food, mild 
stimulants, as small quantities of brandy, wine-whey, the bitter tinctures, 
iron, or quinine, with counter-irritants to the surface of the chest, warm 
clothing, and repose, constitute the necessary and most reasonable reme- 
dies. When, on the contrary, the atelectasial condition supervenes in the 
midst of extensive and severe bronchitis, we are called upon to treat at 
the same moment two morbid states, one consisting of active inflamma- 
tion, and another of want of .power in the muscles of respiration to force 
the atmospheric air through the secretions which are obstructing the air- 
passages. Under these circumstances, there is almost always associated 
with the bronchitis, as we shall find when we come to treat of that 
disease, more or less intense congestion of the collapsed portions of the 
lungs. We must employ, therefore, such remedies as tend to modify the 



138 COLLAPSE OP THE LUNG. 

inflammation of the bronchial mucous membrane, and diminish thereby 
the amount of secretion poured into the air-passages, such as may serve to 
expel mechanically those secretions, and those which shall unload the 
congested lung of its excess of blood, always taking care, in our selection 
of the agents to accomplish these ends, to choose those which are the 
least perturbative and exhausting. To moderate the inflammation of the 
bronchial mucous membrane, we may employ dry cupping, or, if the 
patient be not too much reduced, wet cupping or leeching, but these latter 
with great moderation. For the same purpose, and with a view also to 
unload the congested parts of the lung, counter-irritation is very im- 
portant, and the best mode of effecting this is by the repeated application 
of dry cups, or of mustard poultices, consisting of one-third mustard to 
two-thirds Indian meal or flour. The poultices ought to be applied first 
to the dorsum and then to the front of the chest, once in every three or 
four hours, and they should be made large enough to cover a considerable 
portion of the thoracic walls. Counter-irritation, assiduously made use 
of, is, I believe, one of the most, if not the most effectual means of treat- 
ment in the case. Emetics ought to be given twice a day, or even three 
times, if they do not reduce the strength too much. The best are those 
which operate with the least subsequent prostration, such as ipecacuanha 
or alum. "When they are found to exhaust much, and to increase thereby 
the labor of breathing, their use must be suspended. 

After emetics, or when these cannot be used, the remedies from which 
I have obtained the greatest benefit are the liq. ammon. acetat., and 
seneka, either in decoction or syrup, combined sometimes with small 
quantities of opium. To a child two years old I should give twenty 
drops of the acetate of ammonia solution, with ten of the syrup of seneka, 
or with a teaspoonful of decoction of seneka, every two hours. When 
the cough is paroxysmal, painful, and harassing, about ten drops of pare- 
goric, half a drop or a drop of laudanum, or from four to six drops of 
solution of morphia, may be added to each dose of the spiritus Mindereri 
and seneka. The opiate ought to be continued until the cough and rest- 
lessness diminish, and then suspended. In all these cases, there should 
be no hesitation in giving small quantities of brandy or wine-whey, 
whenever the symptoms of prostration are so marked as to indicate imme- 
diate danger; — when the pulse is very rapid and small, when the skin is 
cool or pale and bluish, and when the general aspect of the patient, and 
the convulsive and labored character of the breathing show that the mus- 
cular strength of the child is scarcely sufficient to carry on the function 
of respiration. 



PNEUMONIA. 139 



ARTICLE II. 



PNEUMONIA. 

Definitions; Synonymes; Frequency; Forms. — The term pneu- 
monia is now, by universal consent, applied only to inflammation of the 
parenchymatous structure of the lungs. It is often called, in this country, 
catarrh-fever, lung-fever, or inflammation of the lungs. 

It is one of the most frequent, and, therefore, one of the most impor- 
tant of the acute diseases of childhood. Dr. West, in a paper on the 
pneumonia of children (Brit, and For. Med. Rev., April, 1843), informs 
us that the English tables of mortality show pneumonia to be the cause 
of a larger number of deaths in childhood, than any other disease, with 
the exception of the exanthemata. From the third report of the registrar- 
general, he quotes the facts, that of all the deaths in the metropolitan 
districts under fifteen years of age, 13-6 per cent, were from pneumonia, 
13-0 per cent, from convulsions, and 54 per cent, from hydrocephalus. 
He obtained nearly similar results from an examination of the returns 
from Manchester, Liverpool, and Birmingham. In the Philadelphia bills 
of mortality, the distinction between pneumonia and bronchitis is so 
imperfect, that it is impossible to obtain data on which to found an exact 
standard of the relative frequency of pneumonia and other diseases. It 
appears, however, not to be so fatal here as in England, since of 18,599 
deaths under fifteen years of age in this city, during the five years from 
1844 to 1848 inclusive, only 1,385, or 13-4 per cent, were from pneu- 
monia and bronchitis combined. 

Any one who will study with attention the various doctrines in regard 
to pneumonia and bronchitis, that have been set forth in the different 
works on the diseases of children published in the last fourteen or fifteen 
years, will most assuredly acknowledge that there are few diseases about 
which there prevails just now a greater diversity of opinion as to the real 
nature of the lesions that form their essential anatomical characters, and 
consequently as to the proper mode of classifying and describing them. 
From the time of the appearance of the works of M. Valleix, M, Barrier, 
and especially that of MM. Rilliet and Barthez, up to the moment of 
publication of the essay of MM. Legendre and Bailly (referred to in the 
article on atelectasis), it was commonly believed that inflammation of the 
parenchyma of the lung exhibited in children very different characters in 
the majority of the cases, from those which marked the pneumonia of the 
adult. Two principal forms of the disease were therefore described by 



140 TNEUMONIA. 

most writers, — the lobular and the lobar. The former was supposed to 
be almost peculiar to children, and to occur only on rare occasions in 
adults; the latter was held to resemble, in almost every respect, the 
pulmonic inflammation of the adult. Moreover, lobular pneumonia was 
generally believed to be by far the most common form assumed by the 
inflammation in children under five years of age, whilst lobar pneumonia 
was thought to be comparatively rare under the age mentioned. Besides 
these two chief varieties of pneumonia, two others have been described 
under the names of vesicular and marginal pneumonia, while to yet ano- 
ther MM. Rilliet and Barthez applied the title of camification. 

The researches of MM. Legendre and Bailly have caused a very 
great revolution in the views of a large number of medical observers 
and writers. These gentlemen assert (as stated in the article on atelec- 
tasis) that a very large proportion of the cases heretofore described under 
the titles of lobular pneumonia, generalized lobular pneumonia, pseudo- 
lobar pneumonia, marginal pneumonia, and the camification of MM. 
Billiet and Barthez, are in fact cases of bronchitis variously associated 
with congestion and collapse of the tissue of the lung. They themselves 
describe these supposed different forms of pneumonia under the title of 
catarrhal pneumonia. But, though they are opposed to the opinion of 
lobular pneumonia being a true inflammation of the lung, they do not 
assert that children are not subject, like adults, to regular inflammation 
of the pulmonary parenchyma. They describe, in fact, as nearly all 
others have done, a lobar pneumonia, which exhibits the same anato- 
mical characters, and very nearly the same train of symptoms, both 
rational and physical, as the pneumonia of adult life; and a partial 
pneumonia, in which the inflammation, instead of invading a large part of 
a lobe or a whole lobe, attacks isolated small portions of the parenchyma, 
so as to present an appearance of nodules of inflammation scattered here 
and there through the healthy tissue. 

Since the publication, in 1844, of the views arrived at by MM. Le- 
gendre and Bailly, numerous other observers have repeated and continued 
their researches, but with very different results. Some have adopted their 
opinions entirely, others in part, while others again adhere tenaciously to 
the old doctrines. Amongst those who now believe that lobular pneu- 
monia in its different forms is in fact bronchitis with collapse of 
the lung-tissue, and not inflammation of the pulmonary parenchyma, 
the most important are Drs. West and W. T. Gairdner (Loc. cit), MM. 
Hardy and Behier (Pathol. Int., t. ii., p. 529, et seq.), and Dr. Fuchs 
(Brit, and For. Med.-Chirurg. Rev., July, 1850, p. 154, et seq.) 
Amongst those who oppose the new views, I may mention the names of 
M. Bouchut, and those of the authors of the Compendium de Medecine 



FORMS — CAUSES. 141 

Pratique. I would refer any one who desires to study this matter as 
treated by English hands to the essay " On the Pathological Anatomy of 
Bronchitis, and the Diseases of the Lung connected with Bronchial Ob- 
struction/' by Dr. W. T. Gairdner, of Edinburgh. It is decidedly the 
best English work on the subject that I have seen, for it treats not only 
of atelectasia in children, but contains yet more numerous observations 
upon the same condition as it occurs in adults. 

My own opportunities for investigating this interesting subject by post 
mortem examination are so few, owing to the small amount of mortality 
that occurs in a private practice, limited almost exclusively to the easy 
classes of society, and also to the prejudices which many hold against 
autopsies, that I have been obliged to form my conclusions in regard to it 
chiefly from a study of the researches of others, and from a comparison of 
the symptoms which I have observed during life in the different pulmo- 
nary affections of children, with those researches, and with the results 
that I have obtained from the few autopsies that I have been able to make. 
Assisted by these combined means of forming a conclusion upon the sub- 
ject, I have been led to the belief that the former method of dividing the 
pneumonia of children into the two forms of lobular and lobar, is incor- 
rect, and I have determined to substitute for the term lobular that of 
partial, which is the one employed by M. Legendre, and very lately also by 
Dr. Alois Bednar (Die Kranklieiten der Neugcbornen unci Saur/Iingc, 
Dritter Thiel, Wien, 1852, p. 65), while I shall describe the other form 
of the disease under its usual title of lobar. Of these two forms, the 
latter is much the most frequent, though it was formerly thought that 
the lobular was more common than the lobar variety, simply from the 
fact that bronchitis attended with lobular collapse (the condition hereto- 
fore almost always described as lobular pneumonia) is much oftener met 
with in children than true pneumonia, either lobar or partial. 

Predisposing Causes. — It is generally believed that pneumonia is 
most apt to occur in the course of other affections. This is certainly true 
in regard to the disease as it prevails in hospitals, and probably amongst 
the poorer classes of society also. Rilliet and Barthez state that of two 
hundred and forty-five cases observed by themselves, only fifty-eight, or 
very little more than a fourth, occurred in children previously in good 
health. The proportion of secondary cases is much smaller in private 
practice, since of thirty-seven cases of well-marked pneumonia, observed 
by myself during the last four years, only four were secondary. No doubt 
one cause of this apparent discrepancy between the authors mentioned 
above and myself, is the fact that I have left out of consideration all the 
cases in which the pneumonic symptoms were not entirely clear, thus 
putting aside a number of cases which they would have classed as lobular 



142 PNEUMONIA. 

pneumonia, but which I prefer to regard as examples of bronchitis with 
collapse. Age forms a strong predisposing influence. Of the two hun- 
dred and forty-five cases above quoted, one hundred and seventy-two oc- 
curred under five years of age. Dr. West (Loc. cit.), says that during 
the first five years of life, the cases of pneumonia were in the proportion 
of 10-3 per cent, to the total of diseases, while in the succeeding five years 
they were in the proportion only of 1-3 per cent. These statements do 
not agree with my own experience, since of the thirty-seven cases that I 
have seen, nineteen occurred under five, and the remaining eighteen be- 
tween five and eleven years of age, showing that the frequency in the first 
five and the subsequent six years of life is very nearly the same. True 
pneumonia is less frequent in private practice in the first two, than in 
the succeeding years of life. Of the nineteen cases that occurred in the 
first five years after birth, two occurred in the first, and three in the 
second year, while five occurred in the third, four in the fourth, and five 
in the fifth year. 

Sex. — A larger number of cases occur in boys than girls. The excess 
is little more, however, than may be accounted for by the preponderance 
of male over female children. Of the thirty-seven cases just referred to, 
nineteen occurred in boys, and eighteen in girls. 

Constitution. — It is doubtful whether constitution has much or any 
influence upon the liability to the disease. Dr. West says that weak 
health is not a predisposing cause according to his experience. I am 
convinced that it attacks strong and vigorous children more frequently 
than those of more delicate constitution. In children of feeble health and 
weak stamina, the very same causes which produce pneumonia in the 
robust, give rise to bronchitis. 

Season. — The disease is most prevalent during the winter months. 
According to the third report of the registrar-general of England, the 
greatest mortality under fifteen years of age takes place in December. 

Previous Diseases. — It is apt to occur as a complication of all the 
diseases of children, and most frequently in measles, pertussis, typhoid 
fever, enteritis, and bilious remittent fever. 

Exciting Causes. — The continued action of some of the predisposing 
causes must be regarded as the exciting cause in the majority of the cases. 
External violence, as a severe fall, or a blow upon the chest, will sometimes 
act as an exciting cause. The action of cold is almost always alleged to 
be the immediate cause of the attack. M. Grrisolle states that it is 
impossible to determine the exciting cause in more than a fourth of the 
cases, and that in nearly all of these it is cold. 

Anatomical Lesions. — Lobar pneumonia in the child is marked by 
the same physical characters as in the adult. The three stages of the 



ANATOMICAL LESIONS. 143 

inflammation, engorgement, red hepatization, and gray hepatization, are 
met with exhibiting the same alterations of the tissues of the lung as are 
observed in adult life. Moreover, the three stages occur with about the 
same frequency in early as in later life. Dr. West (Loc. cit., 2d Ed. ; 
p. 189) shows that the third stage occurs very nearly as often in children 
as in adults, he having met with it in the former in the proportion of 
sixty-eight per cent., while M. Grisolle found it in seventy-two per cent, 
of the latter. The chief difference in the disease, as it exists at the two 
ages, consists in the more frequent co-existence of all three of the stages 
in the young subject. 

In the first stage, or that of engorgement, the affected portion of lung 
is distended, so that it does not collapse in the same proportion as the 
healthy portions, when the thorax is opened. The diseased part is 
heavier than usual, so that it sinks somewhat in water, and it is of a 
brownish-red color ; it pits upon pressure, and crepitates less than healthy 
lung, the crepitation being observable only here and there. The natural 
degree of cohesion between the tissues of the organ is somewhat dimi- 
nished, so that it is much less tough and elastic, and more soft and 
friable than it ought to be. When cut into a large quantity of frothy, 
and more or less deeply tinged, sanguineous fluid escapes. 

In the second stage, or that of red hepatization, the lung is increased 
in volume, so that it continues to fill the side of the chest after that 
cavity is opened ; it is dense and hard, has ceased entirely to crepitate, 
from the fact of having become completely impermeable to air, and sinks 
rapidly when thrown into water. Externally, the diseased portion is of 
a deep red. color, while internally the same color is observed, but often so 
unequal, and of such different shades, as to give to a cut surface a mar- 
bled aspect. The cohesion between the tissues is, in this stage, much less 
strong than in health, or in the first stage of the disease ; the finger pene- 
trates the lung with some ease, and the texture can be crushed between 
the finger and thumb. When cut into, there escapes a non-aerated 
and reddish fluid, which is much less abundant than in the first stage. 
The most important feature of red hepatization is, however, the granular 
character of an incised surface. This granular appearance is produced 
by the presence of numerous flat granular elevations, which appear to 
consist of effused matter that has been thrown out in the air vesicles. It 
is best seen by examining a torn surface of the lung. 

In the third stage, or that of gray hepatization, the lung continues to 
exhibit the same volume, density, impermeability to air, and consequent 
total absence of crepitation, as in the second ; but the process of softening 
has made still further progress, so that a portion of the lung may be 
squeezed with the greatest ease between the finger and thumb into a pulp. 



144 PNEUMONIA. 

The color has now changed from deep red to a dirty light gray, or a pale 
straw yellow. When incised, the surface still presents a granular ap- 
pearance, but the granules are more irregular, and flatter. The diseased 
portions are now infiltrated with a purulent fluid, which escapes in con- 
siderable quantities in the form of a yellowish-gray liquid, whenever the 
lung is cut into. Careful examination in this stage shows that the 
organic elements of the lung are reduced to a homogeneous mass, the only 
parts which remain distinct being the larger vessels and bronchia. 

The anatomical lesions which characterize partial pneumonia occur 
under two conditions. In one, the alterations are exactly the same as 
those of the lobar form, the only difference between the two being that in 
the partial form the hepatization affects distinct patches of the pulmonary 
substance, producing, therefore, hard nodules of hepatization, scattered 
through healthy tissue. These nodules are irregular in form, and imper- 
fectly circumscribed, but present, like the lobar form, the three stages of the 
inflammation, — engorgement, red hepatization, and grey hepatization. The 
second variety of partial pneumonia is characterized by patches of hepati- 
zation, varying in number from fifteen to thirty, and in size from that of 
a hemp-seed to that of a pigeon's egg, which are more or less spherical in 
shape, hard to the touch, and exactly limited. M. Legendre states that 
these hepatized points become transformed into a grayish, rough, and 
uneven substance, of a fibrous appearance, a change which takes place at 
different points of the diseased mass, sometimes in the centre only, some- 
times in their whole extent, and at others in their circumference. 

Abscesses are not very uncommon in the pneumonia of children. They 
occur as a result of the third stage of the disease, so that in the same 
lung may be observed the first, second, and third stages of the inflamma- 
tion, and abscesses. The cavities of the abscesses are generally circular, 
sometimes oval, and they measure from half a line to an inch or more in 
diameter. Sometimes the abscess is niul til ocular, each, of the purulent 
cavities being partially separated from its neighbor by a wall of hepatized 
tissue. They are found in various parts of the lung, but seem disposed, 
generally, to approach the surface of the organ. When the latter event 
happens, adhesive inflammation between the pleura pulmonalis and 
costalis usually takes place, but should this fail to occur, the abscess 
ruptures into the pleural sac, and produces pneumothorax. Rilliet and 
Barthez met with two examples in their autopsies, in which this accident 
had occurred, and they report another case in which it occurred during 
life, and in which the child recovered. I have met with one case of 
pneumothorax myself, produced in the same way. It occurred in a boy 
eleven years old, during an attack of secondary pneumonia, complicating 



ANATOMICAL LESIONS. 145 

a severe bilious remittent fever. The patient recovered entirely, after a 
most violent illness. 

I am desirous before closing my remarks on the anatomical lesions of 
the disease under consideration, of drawing attention to the subject of 
simple, uninflammatory congestion of the lung, for the reason that the 
latter has, no doubt, especially when associated with collapse of the pul- 
monary tissue, been frequently mistaken for pneumonia. 

Congestion of the lung occurs either in the lobular or lobar form, the 
distinction between the two being the same as that between lobular, and 
diffused or lobar collapse. When lobular, the lung presents, generally 
along the posterior edge of the organ, disseminated lobules, distinctly 
circumscribed by the inter-lobular cellular septa, which are rather protu- 
berant than depressed, more friable, and of a lighter purple color than 
collapsed lobules, and which afford, when squeezed, a considerable quan- 
tity of frothless bloody fluid. In very young infants, the congestive 
disposition often assumes the lobar or diffused form, and is supposed by 
M. Legendre to have frequently been taken for pneumonia. (And may it 
not be indeed that these cases are often instances of pneumonia, but 
pneumonia still in the first stage ?) In this variety of congestion, the 
affected portion of the lung is increased in size, and is distended and 
gorged with fluids. The color of the congested part varies from a light 
to a dark purple, or almost blackish tint. The cohesion of the lung is 
also variable, the differences depending on the degree of the congestion. 
When this latter is very great, the part is very friable, while it is much 
less so under the opposite condition of things. Though the lung is 
harder in this state than natural, it still retains a certain degree of flacci- 
dity which does not exist in true hepatization. Pressure causes an 
abundant exudation of blood and serosity from a cut surface, and the 
latter, instead of being granulated, as is always the case in hepatization, 
is smooth and even. Neither does the lung exhibit any granulations 
when it is torn. Lastly, inflation distends all the vesicles, and gives to 
the condensed parts their natural lightness and their rosy color, though, 
be it remarked, the development of the diseased parts under the opera- 
tion is not complete and entire as in collapse, in consequence, no doubt, 
of the large amount of blood they contain. 

Inflation of the lung after death has been much employed of late, as 
any one who has read the previous remarks on atelectasia must have seen, 
as a means of distinguishing between pneumonia and collapse. It was 
there stated that, whilst inflation distended, and restored more or less 
completely to their natural condition, parts of the lung that were merely 
collapsed, it failed almost entirely to have any effect on parts of the lung 
affected with true pneumonia. It is easy to understand why inflation 

10 



146 PNEUMONIA. 

should fail to exert much effect on inflamed lung, at least when the 
disease has reached the stage of hepatization. In fact, the tissues com- 
prising the lung are glued together and hardened, by a deposit of plastic 
lymph, poured out both on the outside and inside of the air-cells, so that 
it becomes impossible to force the air into the midst of the agglutinated 
structures. In the first stage of pneumonia, that of congestion, inflation 
will distend in some degree the affected portions, but, in the second and 
third stages, not even the strongest force has any effect on the impermea- 
ble vesicles. 

Lobar pneumonia is stated by most authorities to be generally confined 
to one lung, and such has been my own experience in regard to it, since 
of thirty-six cases in which its location was carefully determined, it was 
unilateral in thirty-four, and double only in two. It is much more 
common on the right than left side, according to most writers. In the 
thirty -four cases just referred to, the distribution was exactly equal, the dis- 
ease being seated seventeen times on the right side, and the same number 
on the left. It attacks the lower lobe much more frequently than the 
upper. Of thirty-three cases in which this was determined, the upper 
lobe was the part affected in thirteen, while in twenty the base of the 
lung was the seat of the disease. Of the thirteen cases of inflammation 
of the upper lobe, in nine it was seated on the right, and in four on the left 
side. Of twenty cases occurring in the lower lobes, seven were on the right, 
and thirteen on the left side. In the two cases of double pneumonia, the 
inflammation attacked the lower lobes of both lungs in one, while in the 
other it attacked first the base of the left lung, and afterwards the summit 
of the right. 

The statements just made as to seat of the pneumonic inflammation in 
the cases that have come under my own observation, do not, I am well 
aware, agree exactly with the experience of other observers. Dr. West, 
for instance, found (Loc. cit., p. 190) that double pneumonia preponderated 
greatly, in early life, over those wherein only one lung suffered. This, 
it will be observed, is widely different from the result of my experience, 
and it is also directly opposed to that of MM. Billiet and Barthez, Rufz, 
and Barrier. M. Barrier, in fact, cites (MaL de L'Unfance, t. i. p. 286) 
one hundred and forty-four cases of lobar pneumonia as having been ob- 
served by the authors just mentioned, and by himself, and of these only 
fifteen were double. My results in regard to the frequency of double 
lobar pneumonia agree, therefore, with those of the authors last men- 
tioned, but they differ as to the relative frequency with which the two 
lungs are attacked. Thus, in my cases, the inflammation occurred with 
equal frequency in the two lungs, whilst of one hundred and twenty-nine 
cases of unilateral pneumonia observed by the above authors, eighty-four 



ANATOMICAL LESIONS. 147 

were seated in the right, and forty-five in the left lung. These writers 
state, as most others do, that pneumonia of the lower lobe is more com- 
mon than that of the upper lobe. This tallies with my observations, but, 
as it seems to be a general opinion in the profession, that inflammation of 
the summit of the lung is rare, in comparison with that of the base, I 
wish to call attention again to the fact stated above, that of thirty -three 
cases, in which I ascertained accurately the seat of the disease, it was 
in the upper lobe in thirteen, and in the lower, in twenty. 

It was formerly supposed that bronchitis was an exceedingly frequent 
accompaniment of pneumonia, and there is no doubt that such is really 
the fact in a much larger proportion of the cases that occur in children, 
than of those that occur in adults. But, since the discovery of the nature 
of the anatomical alteration, which we have described under the title of 
collapse or atelectasis, it has become clearly evident that one reason why 
it was thought that bronchitis so generally accompanied the pneumonia 
of children, has been, that a large number of cases, heretofore classed as 
pneumonia, were in reality cases of bronchitis attended with collapse. I 
have shown, indeed, in the preceding pages, that there is good reason to 
believe that a very large majority of the cases hitherto described as 
lobular pneumonia, ought to be classed under the head of bronchitis. 
Now, these cases are precisely those in which bronchitis has been found 
to occur so constantly, and to form so large a portion of the disease, and 
they, moreover, have always been stated to be of much greater frequency 
than cases of lobar pneumonia. If, however, we conclude to regard what 
was formerly called lobular pneumonia, as bronchitis, and to restrict the 
title of pneumonia to the cases in which there is a true hepatization of the 
lung, we shall have left only lobar pneumonia, which is not at all a rare 
affection, and partial pneumonia. Now, in the lobar pneumonia of chil- 
dren, as in that of adults, bronchitis does not usually exist to any very 
considerable extent, and we may state, therefore, that, though bronchitis 
exists to a greater or less extent in most of the pneumonic cases of chil- 
dren, it is in a much less severe degree than was at one time supposed. 

When bronchitis is present it varies from simple increased vascularity 
with augmented mucous secretion, to intense congestion with purulent or 
pseudo-membranous secretions. 

Pleurisy is a frequent complication, as it is found to exist in about half 
the cases. 

Emphysema is another common complication. It generally occupies 
the upper part of the lung, or its free edge, and is found most strongly 
developed in the lung which presents the greatest amount of inflamma- 
tion, or in both, when both are inflamed. Its degree depends on the 
extent of the pulmonary inflammation and bronchitis, and the severity of 



148 PNEUMONIA. 

the dyspnoea. The vesicular form is much more frequent than the inter- 
lobular. 

Symptoms; Sketch of the Disease; Course. — In order to present 
a faithful account of the disease, a general sketch of the symptoms will 
first be given, after which the most important ones will be considered 
separately under the head of particular symptoms, so that the reader 
may first obtain a notion of the course of the disease, and then become 
intimately acquainted with its details and peculiarities, by reference to 
the remarks on each particular symptom. 

True pneumonia, with well-marked hepatization, is not, according to 
my experience, a common affection in young infants in private practice, 
since out of thirty-seven cases of the disease that I have met with in 
children, only two occurred in infants within the first, and three in the 
second year. Of the two cases within the year, one occurred in a child 
six weeks old, and the other in one seven months. 

In new-born children, and those still at the breast, pneumonia very 
generally begins with more or less marked symptoms of bronchitis, though 
in some instances it commences suddenly, as it does in adults, without 
any previous sign whatever of bronchial inflammation. When it occurs 
during an attack of bronchitis, the symptoms which belong to the pneu- 
monic inflammation will, of course, have been preceded by those which 
depend on the disease of the bronchial mucous membrane. In these 
cases, the development of the pneumonia will be indicated by an aggra- 
vation of the general symptoms, by an increase of the oppression, by the 
fact that the cough and breathing both become more painful than before, 
and by the occurrence of the physical signs peculiar to pneumonia, or, 
in other words, by the symptoms which depend upon and mark a state of 
inflammation of the parenchyma of the lung. Of these I shall now give 
an account. 

"When pneumonia appears as a primary affection in young children, 
without preceding bronchitis, as sometimes undoubtedly happens, though 
much less frequently than in children over five years of age, and especially 
than in adults, the attack is usually sudden. The first symptoms observed 
are restlessness, peevishness, disposition to cry, a diminished appetite for 
the breast, and feverishness. These symptoms are most marked in the 
evening and night. From the very first, or by the second day at least, 
cough is heard, and careful examination of the breathing will show that 
it is somewhat hurried. The cough is dry, short and hacking, at first, 
and not very frequent, but it soon becomes louder, fuller, more straining, 
and especially it becomes painful. The fact that it is painful may always 
be ascertained by watching the motions of the child, its cry, and the ex- 
pression of the face. We can always perceive, even in an infant, a dis- 



SYMPTOMS. 149 

position to restrain the cough, to smother it, a struggle to make it short 
and sudden, when it causes sharp pain. At the moment of the cough 
too, a marked expression of pain, a kind of sudden grimace or twisting of 
the features, may always be observed, which is accompanied or followed 
instantly by a loud, sharp cry, or a spell of crying. This grimace of pain, 
with the accompanying cry, I have never observed in their most character- 
istic form in simple bronchitis, but only in pneumonia and pleurisy. I 
have twice seen these symptoms so decidedly marked, that they could not 
fail to have drawn any one's attention ; once in an infant six weeks old, 
who died of a most violent and extensive pleuro-pneumonia, and again in 
a child thirteen months old, who died of pleurisy resulting in a deposit of 
pure pus in the pleural sac. The nature and extent of the lesions were 
ascertained, in both cases, by examination after death. The presence of 
pain in the side is shown also by the fact that full inspirations, caused by 
changing the position of the child, and those which occur during fits of 
crying, occasion a sudden arrest or stoppage, so to speak, of the act of 
inhalation, which gives to the crying, and often also to the breathing, a 
sobbing character, while across the countenance passes at the same moment 
the expression of pain already referred to. The breathing, which is only 
slightly disturbed at first, soon becomes frequent and attended with more 
or less effort, and gives rise to an unusual play of the nostrils, a symptom 
which ought always to attract attention to the respiratory system as the 
seat of disorder. It interferes also with the act of nursing, so that whe- 
ther the child takes the breast less frequently than usual, from want of 
appetite, or seeks it with greater avidity than common, from thirst, the 
act of sucking is always attended with some difficulty. The infant seizes 
the breast for a few instants, then lets go in order to breathe more 
easily and seizes it again ; or it drops the nipple suddenly and begins to 
cry, as though the act of sucking were painful from the necessity it begets 
of taking occasionally a fuller and deeper inspiration than usual. As a 
general rule, the bowels are torpid, while vomiting, which is rather un- 
usual in older children, is quite common in young infants. 

When the disease is once established, whether it have been preceded 
by bronchitic symptoms, or occur as a primary affection, the symptoms are 
generally well marked, so as to leave but little difficulty in the recognition of 
the disorder. The child now loses all gaiety and cheerfulness and becomes 
either dull and listless, or very restless, peevish, and troublesome. Young 
infants generally lie quietly on the bed, or in the lap, merely fretting and 
crying when they cough, or when they are moved for any purpose, while 
children of several months old, and those in the second year, are usually 
very cross and restless, crying and screaming when anything is done for 
them, and insisting upon being frequently moved from the cradle or bed 



150 PNEUMONIA. 

to the lap, or from the lap to the cradle. As a general rule they are 
contented only upon the lap, always crying to get back when they are re- 
moved from it to the cradle or crib. In some instances, however, they, 
like young infants, are quiet and dull, being content to lie still when 
placed in a comfortable position, and crying only after coughing, for the 
breast or drink, or when they are disturbed. 

A febrile reaction now displays itself in full force. The skin becomes 
hot and dry, and the pulse frequent, rising to 150 and 160 or higher, 
in infants, and to 140 and 150, or even 160, in those of several months 
old. The dyspnoea becomes more and more evident. The respiration rises 
to 60, 70, 80, or even higher. In a case of pleuro-pneumonia at six 
weeks of age, I counted it at 128. The breathing is at the same time 
more or less labored and difficult, the alae nasi being seen to dilate 
spasmodically at each inspiration, while the motions of the chest, and 
especially those of the abdomen are much stronger and more active than in 
healthful respiration. The cough is now more frequent than before, 
evidently painful, and usually dry, though sometimes a slight degree of 
looseness may be detected in the sound which it occasions. 

Percussion now reveals manifest dulness over the seat of disease, which 
is usually the base, though not at all unfrequently the upper region of 
one side. When the disease is double, which is oftener the case, as already 
stated, in children, than in adults, though not so often as has been sup- 
posed by some, the percussion will be dull of course over the inferior 
regions of both sides behind. Together with the dulness of sound on 
percussion, and sometimes when this is faintly marked, there is an evident 
diminution of elasticity of the walls of the chest, and this becomes there- 
fore an important symptom, especially when dulness on percussion is 
absent. The dulness on percussion is not, however, so marked a symptom 
in infants as in adults, from the fact that the natural sonoreity of the 
chest is so much greater in the former than the latter. 

Auscultation reveals over the diseased part distinct and abundant fine 
subcrepitant rale, but the crepitant rale or fine crepitation, which is the 
pathognomonic sign of pneumonia in adults, and which in them is rarely 
wanting, is absent in young children, or is heard only when they make 
deep and free inspirations. It is most apt to be heard in young children 
during the deep inhalations which they make just before crying, or during 
the act of crying. It is, therefore, much less constant, less strongly 
marked, and more fugitive, in children than in adults, and is, in the for- 
mer, replaced in good measure, by a fine subcrepitant rale. In connexion 
with these symptoms we always have more or less well-marked bronchial 
respiration. This may be pure, which is rarely the case ; it may be, as 



SYMPTOMS. 151 

usually happens, associated with crepitant or subcrepitant rhonchus, or it 
may be heard only in the expiration. 

The symptoms above described show that the inflammation has reached 
the second stage, or that of red hepatization. After attaining this point, 
the disease usually remains stationary for a few days, and then either 
subsides, in favorable cases, by the resolution of the inflammation, or, 
in unfavorable cases, terminates fatally in this stage, or else passes 
into the third stage, and causes death by a more or less extensive 
suppuration of the lung. In favorable cases, which are said to be rare 
in very young infants, but more common in those several months old, 
and in the second year of life, the severity of the symptoms gradually 
diminishes. The fever subsides, the pulse becoming less frequent, and 
the skin cooler and less dry ; the breathing becomes easier and slower, 
and is attended with less pain ; the cough grows looser, less frequent, less 
difficult, and ceases to be painful ; the child begins to nurse without pain 
and with greater ease and facility; the restlessness and fretfulness, or the 
somnolence, when that has been a marked symptom, diminish, and the 
child becomes more placid, and sleeps quietly and tranquilly. The chest 
is now less dull than before on percussion; the bronchial respiration begins 
to diminish in intensity, and is very much masked by the subcrepitant 
rale, which becomes more and more evident, until at last it takes the 
place entirely of the bronchial breathing. The symptoms continuing to 
amend, the physical signs of the disease cease at length to be perceptible, 
the cough grows more and more loose and rare, the countenance becomes 
natural, the fever ceases, and convalescence is fully established. 

In unfavorable cases, death may occur rather suddenly in the second 
stage, without any very decided change in the physical symptoms, from 
exhaustion or from the supervention of collapse of portions of the lung- 
tissue. In these cases,, the breathing becomes more and more rapid 
and labored, or it becomes slower than before ; the moist rales increase in 
abundance and extent, while the percussion often remains about the same ; 
the difficulty of sucking increases, so that the child, when put to the breast, 
attempts to draw but two or three times, and then lets go exhausted and 
distressed, or it makes no effort whatever ; the cough becomes less fre- 
quent, but is still painful and difficult; the skin grows pale and white, 
excepting about the face, hands, and feet, where it assumes often a bluish 
or cyanotic hue ; the extremities, and often the face too, become cool ; the 
child becomes exceedingly restless, and then dull and perfectly quiet, or 
comatose, and death at last occurs from asphyxia. In another class of 
cases, which, however, are much more rare in very young children than 
in older ones, the disease passes into the third stage, or that of suppura- 
tion. In such cases the febrile symptoms continue much longer than in 



152 PNEUMONIA. 

those just now described; the pulse becomes, and continues for several 
days together, very frequent and jerking; the skin retains its heat and 
dryness, though it is often pale at the same time ; the child is usually 
excessively irritable and distressed ; the breathing is rapid and oppressed, 
and often very irregular and uneven ; the dulness on percussion extends ; 
the bronchial respiration becomes more distinct and is heard over larger 
surfaces, and is accompanied with less of the subcrepitant and crepitant 
rales ; the cough is paroxysmal, painful, and often very harassing ; the 
appetite is lost, and the sleep uneasy and often broken. These symptoms 
continue for several days, or a week or two, when they assume the same 
characters they exhibit in more rapidly fatal examples; that is to say, 
asphyctic phenomena develope themselves, and the child dies exhausted 
and comatose, or perhaps convulsed, or after presenting for some hours, or 
a day, more or less severe spasmodic aifections of different muscles or 
of the extremities. 

The lobar pneumonia of children over two years, and especially of those 
over five years of age, exhibits most of the symptoms that characterize 
the same disease in adults. The chief differences to be noticed at these 
two periods of life, are the greater predominance of bronchitis in children, 
particularly in those under five or six years of age, which gives to the 
physical signs some peculiar features not observed in adults ; the frequent 
absence of expectoration, and, when it is present, certain differences be- 
tween it and that of adults; certain peculiarities in the character and seat 
of the side-pain ; and the existence in many instances of more marked and 
more dangerous nervous symptoms. 

The mode of onset is very different in different subjects. Generally, the 
attack begins with violent fever, increased frequency of breathing, more or 
less pain in the side, and short, dry cough. In such cases there is no 
difficulty in perceiving that the disease consists of some form of thoracic 
inflammation. But, in other instances, instead of this open and frank de- 
velopment, the disease comes on with symptoms which might well mislead 
any but a very attentive and competent physician, as to the true nature 
of the case. The most common cause of obscurity is a predominance of 
the nervous symptoms, which often gives to the case very much the aspect 
of a meningeal inflammation. In one example that occurred to myself, 
a boy between six and seven years old was seized, after a short exposure 
during a ride on a raw and cold day, with violent fever, pain in both ears, 
severe frontal headache, and great sensibility to light when exposed to it. 
He was, at the same time, very drowsy, sleeping nearly the whole day, 
but could be roused whe'n loudly and vehemently spoken to, so as to 
answer a few questions and manifest great irritability, and, what was 
extremely suspicious of disease of the brain, when taken with the other 



SYMPTOMS. 153 

symptoms, lie vomited frequently. On the second day, the headache was 
very severe, the sensibility to light continued excessive, and he still vomited 
frequently, rejecting even water. The bowels were freely moved. There 
was up to this time no full cough, but only an occasional, and slight 
hacking, that scarcely drew attention. The respiration was accelerated, 
but there was no dyspnoea. No pneumonia could be detected, though 
carefully sought after. On the third day, the breathing was still more 
frequent, but not at all laborious j the vomiting continued, but the other 
nervous phenomena had lost some of their intensity, and auscultation 
revealed well-marked bronchial respiration before and behind, over the 
summit of the right lung, while over the same regions the percussion was 
dull. I have met with several cases in which the onset of pneumonia was 
attended with nervous symptoms that made the diagnosis difficult and 
obscure. 

In other cases the onset of the disease is marked by symptoms of gastro- 
intestinal irritation, or by such a degree of fever and disturbance of the 
nervous system, with absence of evident local phenomena, as to render the 
nature of the attack obscure and uncertain. In one, for instance, occur- 
ring in a boy betwen four and five years old, and six weeks after recovery 
from measles, the attack began suddenly with violent fever, great restless- 
ness and distress, vomiting, and distension of the abdomen. The case 
appeared to be one of gastro-intestinal disorder, as there was nothing to 
call attention to the thorax. On the second day, the symptoms were much 
worse, the skin being hot and dry, and the pulse one hundred and sixty in 
the minute, and jerking. The child was drowsy and heavy ; it was difficult 
to make him answer questions, and his answers were confused and unin- 
telligible ; his movements were tremulous and uncertain. The tongue was 
dryish and very thickly coated, and he complained confusedly of pain in 
the abdomen, which was much distended, and sonorous on percussion. 
There was no sign of respiratory disease, except some quickening of the 
breathing, and a very slight cough, scarcely to be noticed. At this 
moment, however, when scarlet fever was apprehended, from the great 
frequency of the respiration, the drowsiness, and the tremulous character 
of the muscular movements, auscultation and percussion revealed the true 
nature of the sickness in the shape of a lobar pneumonia of the lower lobe 
of the left lung. 

In a majority of the cases, however, instead of the obscure and decep- 
tive onset I have just described, pneumonia begins with fever, accelera- 
tion of the respiration, pain in the side, and short, dry cough. In some 
instances, the disease supervenes upon catarrh or bronchitis. The child 
ceases to play, refuses to be amused, and is either irritable and cross, or 
lies listlessly upon the bed, or, if still quite young, insists upon being 



154 



PNEUMONIA. 



kept upon the lap. In some few cases, in very young children, convul- 
sions occur. The appetite is lost, or else very much diminished; the 
thirst is acute, and the disease once established, more urgent than in 
almost any other disease. Vomiting is quite common, especially in young 
children, but diarrhoea is rare, the bowels being generally more torpid 
than usual. From the first day often, and almost always by the second, 
we can perceive either crepitant or subcrepitant rhonchus, and sometimes 
bronchial respiration, confined usually to one side, and more frequent 
below than above, though, be it remarked, not at all rare, over the latter 
part. 

As the case proceeds, the fever increases, the bronchial respiration be- 
comes more distinct and is heard over a larger extent of surface, whilst 
the rales diminish in abundance. The skin is now very hot and dry, so as 
to impart a burning sensation to the hand ; the pulse augments in fre- 
quency, seldom counting less than 140 in the minute, often mounting to 
160, and in severe cases, and in young children, even to 170, and be- 
coming full and hard ; the respiration becomes more and more accelerated, 
until it rises to 40 or 50, and in a great many cases to 60, 70, or even 80, 
while it often becomes at the same time oppressed, and, when full inspira- 
tions are made, painful; the cough is frequent, dry or almost dry, and 
painful at first, but after a few days begins to be moist, and in children 
over six or seven years of age is not unfrequently attended with an ex- 
pectoration of rusty or sanguinolent sputa; the thirst continues intense, 
the appetite is null, and the child is very restless and irritable, or drowsy 
and inattentive. About the fourth or fifth day, as a general rule, the 
disease has attained its height, the febrile and local symptoms being then 
most marked, and the extent of the inflammation greatest, as shown by 
the physical signs. 

At this stage of the disease the bronchial respiration is generally 
strongly marked, being clear and distinct, audible both in inspiration and 
expiration, and accompanied by bronchophony or increased resonance of the 
cry. The dulness on percussion is also very evident, the change from the 
natural sound being easily perceptible on a comparison of the two sides. 

The symptoms generally remain stationary at this point for one or two 
days, and then begin to subside. The heat of skin diminishes and perspi- 
ration often appears ; the pulse falls in frequency and force ; the respiration 
becomes slower, easier, and full inspirations can be taken without pain ; the 
alae nasi no longer dilate ; the cough becomes quite loose, and ceases to be 
painful ; the thirst is less acute ; the child loses some of its irritability and 
restlessness, and if it have been soporose and dull, becomes more wakeful 
and observant; the flushing of the face disappears, while the expression is 



SYMPTOMS. 155 

more natural. On auscultation, the bronchial respiration is found to have 
lost some of its intensity ; it has become more distant, or it is heard only 
in the expiration, and is mingled with or in part replaced by crepitant or 
abundant subcrepitant rhonchus. The dulness on percussion is less marked. 
A little later, the fever ceases entirely; the respiration reassumes its natural 
rate ; the appetite returns ; the thirst disappears ; the cough subsides very 
much, and the child begins to be interested in its toys or occupations. 
About the tenth or fifteenth day, and in some cases rather earlier, con- 
valescence is fairly established, though auscultation may still reveal some 
prolongation of the expiratory sound and diffuse resonance of the voice. 

In unfavorable cases, death seldom occurs early in the disease, but 
usually at some distance of time from the invasion, and in consequence, 
no doubt, of the transition of the inflammation into the third or suppura- 
tive stage. In such cases the disease has usually pursued the course just 
described up to the period of resolution, but, instead of resolution and con- 
valescence taking place, the fever continues, though perhaps with di- 
minished violence, the skinfoeing less intensely hot, and the pulse less full 
and active, while it remains quite as frequent. The breathing is some- 
times less frequent than before, but it is often more laborious, and very 
generally it becomes irregular and is easily hurried under exertion. The 
cough varies very much, being sometimes almost suppressed, and in other 
cases very troublesome; it is almost always loose. The strength di- 
minishes, the voice becoming weak and feeble, and the muscular move- 
ments tremulous and languid ; the face looks pale, haggard, and sunken ; 
the child is sometimes very restless, tossing about from time to time on 
the bed or lap, with a quick, short, and evidently feeble movement, or it 
is dull and soporose, awakening only when spoken to, but showing then by 
its fretfulness and peevishness, that its intelligence is retained. While 
these symptoms are present, the extent over which the bronchial respira- 
tion is heard has generally augmented, showing the gradual extension of 
the hepatization, while outside of the part where the respiration is blow- 
ing, and sometimes over the same part, and intermingled with that sound, 
are heard more or less copious subcrepitant and mucous rales. This con- 
dition seldom lasts more than two or three days, at the end of which time 
the child dies in a state of coma, or after one or more convulsive seizures, 
which are the result of a gradually increasing asphyxia. 

In other cases, again, the termination is more gradual. The child, 
after presenting many of the above symptoms, may seem to improve some- 
what. The fever may diminish, the appetite return to some extent, the 
respiration become easier, the restlessness subside, and the child be- 
come more cheerful again ; but the face continues pale, emaciation makes 



156 PNEUMONIA. 

progress, the appetite fails again, the pulse remains frequent, diarrhoea 
comes on, the cough becomes more troublesome, thrush often attacks the 
mouth, the strength decays continually, and, after some weeks perhaps of 
struggling, the child dies in a state of great emaciation and debility. 

The symptoms of partial pneumonia are much more obscure and uncer- 
tain than those of the lobar form of the disease. Owing to the fact that 
the inflamed patches of the lung are disseminated, or scattered, through 
healthy portions of the organ, the signs afforded by physical examina- 
tion are either very imperfect, or entirely masked by the sounds pro- 
duced in the healthy texture. We are forced, therefore, to depend 
much more in this than in the lobar form, on the rational symptoms, 
in determining the nature of the sickness. The rational symptoms of 
partial pneumonia are nearly the same as those of the lobar form. 
The chief differences between the two are in regard to the pain, the 
dyspnoea, and when there is expectoration, in the amount of the sputa. 
The febrile and nervous symptoms, and the disturbances of the digestive 
system, are the same in the two forms, the only difference being in their 
degree of severity. In the lobar variety they are usually more acute and 
severe than in the partial. The local symptoms present important dif- 
ferences which should be noted. In the form under consideration, the 
pain is either wanting entirely or much less acute than in the lobar form. 
When the inflamed patches are few in number, and seated in the central 
parts of the lung, there is an entire absence of pain j but when they are 
more numerous and superficial, pain is complained of, but it is usually 
diffuse, of slight intensity, changeable, and felt only during cough or 
during full inspirations. It makes its appearance commonly on the first 
day, and very seldom after the third. Cough is rarely wanting. It usually 
marks the onset of the sickness, is extremely variable as to its frequency 
and severity, and is not acutely painful, as in the lobar form, unless the 
inflamed patches be superficial. There is seldom any considerable amount 
of expectoration, and in some cases none ; when there is any it is small in 
quantity, and it may or may not be characteristic. In one case, however, 
that came under my observation, in which I had every reason to believe, 
from the nature of the rational symptoms, and from the absence of physical 
signs, that the disease was partial pneumonia, there was a rare expectora- 
tion of thick, viscous mucus, streaked with blood. The respiration is ac- 
celerated, and when the lesion is at all extensive, there is dyspnoea, the 
degree of the acceleration and dyspnoea being determined by the extent 
and number of the inflamed patches. 

The physical signs are, as above stated, not very significant. The 
percussion is natural, the amount of tissue consolidated being insufficient 
to affect the sonorousness of the chest. Auscultation affords no signs of 



DURATION — PARTICULAR SYMPTOMS. 157 

the pneumonic inflammation when the number of affected patches is 
small ; when they are more numerous it is of some, but not of very great 
utility. Crepitant rale is sometimes heard here and there oyer circum- 
scribed points of the thorax, and, disseminated in the same way, there is 
also heard in some instances rude respiration, prolonged expiratory mur- 
mur, and bronchial respiration. When, as sometimes happens, this form 
of the disease coexists with bronchitis, it will be entirely concealed by 
the dry and moist rales of the latter affection. 

The duration of pneumonia has been fixed with considerable accuracy 
by the observations of various persons. As a general rule, the disease 
reaches its highest point of severity in about four or five days, then 
remains stationary for one or two days, and diminishes regularly until 
between the tenth and fifteenth day; when convalescence is established. 
In my own practice, the longest duration in nineteen unmixed cases, in 
which the period was accurately noted, was fourteen days, and the 
shortest was five. The duration in the nineteen cases was as follows : 
one case lasted fourteen days ; one lasted eleven ; three lasted ten ; five 
lasted nine j three lasted eight ; two lasted seven ; two lasted six ; and 
two lasted five days. One case lasted thirty-three days, but it was 
accompanied and followed by bronchitis. 

Particular Symptoms; Physical Signs. — In order to practise aus- 
cultation and percussion in a young child, it should be placed by the 
mother in a sitting posture on her knee, while the physician, kneeling on 
the floor, or sitting on a low chair, makes the examination he deems 
necessary. If the child be old enough to take notice, it should be at- 
tracted and amused by some toy or glittering object. Even, however, 
should it cry violently, much valuable information is to be obtained by 
the examination, for we can ascertain the presence or absence of rhonchi 
and their characters during the deep inspirations between the cries, and 
can observe resonance of the cry and cough, and practise percussion. 

The physical signs of lobar pneumonia are crepitant or subcrepitant 
rhonchus, feeble respiration, bronchial respiration, bronchophony, resonance 
of the cry and cough, and dulness on percussion. They are, in fact, the 
same in the great majority of cases as in adults. Under five years of age, 
this form often begins with subcrepitant rhonchus, while after that 
period, the earliest stethoscopic signs are crepitant rhonchus, or feeble 
respiration. The bronchial respiration makes its appearance soon after 
the subcrepitant or crepitant rhonchus, is heard first in the expiration, 
and then in both inspiration and expiration, and is accompanied by bron- 
chophony, resonance of the cry and cough, and dulness on percussion. 
Bronchial respiration was present in thirty of the thirty-seven cases of 






158 PNEUMONIA. 

lobar pneumonia observed by myself; crepitant r&le was present in 
seventeen, and subcrepitant in nine. 

These alterations of the auscultatory phenomena are confined to one 
side, in the great majority of cases, and are best observed over the pos- 
terior inferior portion of the lung. Rilliet and Barthez state that they 
have never known the bronchial respiration to disappear, in favorable 
cases, before the fifth day, and in the majority not before the seventh, 
eighth or ninth; while in fatal cases, it continued to the moment of 
death. Its persistence is always a highly unfavorable symptom in very 
young children, whilst in those who are older, as in adults, it sometimes 
remains for several days or weeks, though the general symptoms have 
entirely disappeared. 

Rational Symptoms. — Cough may be said to be invariably present. 
It is dry at first, and not very frequent, but in one or two days becomes 
more frequent, often very troublesome, and from dry and harsh, becomes 
more or less humid and loose. It continues until the disease moderates, 
lasting generally from nine to sixteen days. In fatal cases it usually 
persists to the last. In infants it is not very frequent, occurs in short 
paroxysms, and in fatal cases often ceases one or two days before death. 
Rilliet and Barthez remark that in pneumonia of the upper lobes, it has 
a peculiar character. It is little, short, smothered as it were, or piercing, 
teasing, or slightly hoarse. I will merely add that cough is sometimes 
scarcely noticeable in cases which simulate hydrocephalus, during the 
early part of the attack. In one case that occurred to myself, already- 
referred to, in which the symptoms bore for several days very much the 
aspect of a meningeal attack, there was no full cough whatever during 
the first two days ; on the third day, though auscultation and percussion 
showed the existence of pneumonia of the upper lobe of the right lung, 
the child coughed only three or four times, and it was not until the sixth 
day that it became at all frequent. In three other cases the cough was 
so slight in the early stages of the disease, during the continuance of the 
cerebral symptoms, as not to have been noticed unless particularly in- 
quired after. Later in the attack, after three, four, or five days, and as 
the cerebral symptoms moderated, the cough became frequent and loose, 
and the pneumonic symptoms pursued their regular course. 

Expectoration is almost invariably absent under five years of age. 
Rilliet and Barthez, and Gerhard, have never observed rust-colored 
sputa under the age mentioned. In older children there is sometimes, 
though not very often, voluntary expectoration. Even in them, however, 
the sputa seldom present the characteristic rust- color and viscidity ob- 
served in adults, but consist simply of mucus tinged with blood, or of 
whitish, brownish, viscous or non-viscous phlegm. I once, however, saw 









PARTICULAR SYMPTOMS. 159 

a child three and a half years old, voluntarily expectorate viscid mucus, 
tinged copiously with blood. Sanguinolent expectoration was noticed in 
five of the thirty-seven cases seen by myself (not including the one just 
spoken of). In three the sputa were of the characteristic rusty color; 
in one they were composed of mucus streaked with blood, and in another, 
portions of mucus streaked with blood were rejected by coughing, and 
some also by vomiting. The ages of the five subjects just alluded to were 
in all between five and nine years. In another case (not included amongst 
the five), in a girl seven years old, affected with lobar pneumonia super- 
vening upon pertussis, there was a free expectoration of tenacious mucus, 
sometimes streaked or dotted with blood, sometimes brownish, and at 
others rust-colored. 

Valleix mentions a whitish or sanguinolent viscous froth, as sometimes 
escaping from the mouth of new-born children laboring under the dis- 
ease. I have never met with this symptom, but know of one case of a 
child within the month, who, during an attack of pneumonia, vomited 
mucus tinged with blood. The child died, and presented the lesions of 
pneumonia. The nipples of the mother were perfectly healthy, so that 
the blood could not have been sucked by the child from them, but must 
have been the sputa which had been swallowed, after being coughed into 
the fauces. 

It is scarcely necessary to say that the absence of expectoration is only 
seeming, for children undoubtedly reject sputa into the fauces and swallow 
them. 

Thoracic pain. — It is impossible to ascertain the presence of this 
symptom with positive certainty prior to the age at which children talk, 
and very often not for some time after, as they refuse, or do not know 
how, to describe their sensations. And yet, even in infants, the presence 
or absence of the stitch in breathing, and of pain in coughing, may be 
inferred almost with certainty by watching the gestures and expression 
of the child, and the cries, which accompany a full inspiration and the act 
of coughing. In effect, deep inspirations induced by moving the child, 
those which take place during vomiting and gaping, and those also which 
occur in the act of coughing, cause the child to cry out suddenly and 
sharply, and give at the same moment an expression of acute suffering 
to the countenance, which can be referred to nothing else than the causes 
just mentioned, and which reveal almost as plainly as words the painful- 
ness of a deep inhalation and of the act of coughing. In older children, 
I have several times known the pain to be most intense, causing bitter 
and repeated complaints, with crying, fretting, and evident acute suffer- 
ing. The seat of pain, as complained of by children who talk, ought 



160 PNEUMONIA. 

also to be noticed, since the account given by them might well mislead 
an unwary and inexperienced physician. It is quite common, in fact, for 
them to refer the pain to the false ribs, to one of the flanks, to the abdo- 
men, and even to the hip. 

The respiration is always quickened, except where the constitution of 
the patient has been greatly deteriorated by long and severe illness or 
other causes, under which circumstances it may remain at the normal 
rate, or be very slightly accelerated. This symptom usually dates from 
the invasion, soon after which the breathing rises as high as 40, 50, and 60 
in the minute in older children, and from 60 to 80 in the younger. It 
sometimes becomes excessively rapid, attaining, as it did in a case of pleuro- 
pneumonia in an infant six weeks old under my charge, 128. In favorable 
cases, the acceleration subsides usually about the seventh, eighth, or ninth 
days. In most of the cases the breathing is even and regular, while in others 
it is short, abdominal, uneven, and jerking. When the dyspnoea is very great 
in a young child, the nostrils dilate widely, the mouth remains open, and its 
angles are drawn downwards and outwards; the last of these symptoms 
is almost a fatal one. Sometimes the rhythm of the function is changed, 
so that it begins with a sudden, active, and moaning expiration, followed 
by the inspiration, after which comes the interval of rest. Rilliet and 
Barthez state that unequal, jerking respiration, occurs almost exclusively 
in cases of inflammation of the upper lobes. 

Physiognomy. — The face is almost invariably flushed. The color, at 
first scarlet, becomes after a day or two deeper and darker, and in severe 
cases assumes a livid red tint. I have noticed in very severe pneumonia, 
in addition to the deep red tint, a peculiar glazed appearance of the skin, 
which looks as though it had been varnished, while the edges of the flush 
are distinct and abrupt. The lips are generally deeply colored, simulta- 
neously with the face. The flush commonly subsides about the same 
time, or a little before the diminution in the rate of the respiration. In 
fatal cases, the face is apt to lose its color and become pale and sallow, 
as the unfavorable symptoms become more and more marked. The 
pallor of the face is most striking in severe and fatal cases occurring in 
infants ; the face is blanched, and the features pinched. 

The expression of the face is one of anxiety and oppression in the early 
stage ; in very severe cases, or those about to terminate unfavorably, the 
features become drawn and contracted. 

Fever exists in all the idiopathic cases. The pulse, at all ages, is 
rarely under 130 from the first to the sixth or seventh day; in the 
youngest children it rises as high as 140, 160, and even 180; while 
in those who are older, it is seldom above 140. In favorable cases, 



PARTICULAR SYMPTOMS. 161 

it diminishes about the fifth, sixth, or seventh day. In fatal cases, 
it is apt to diminish at the same period, but soon becomes more frequent 
and continues so to the end. 

The skin is hot in the beginning, and continues so until the disease 
subsides. The heat is intense in severe, but not so great in milder 
cases. 

The nervous system shows more or less marked symptoms of disorder. 
There is restlessness, peevishness, and irritability during the day, and these 
increase towards evening. As the night advances, the child becomes still 
more restless ; infants will not sleep except in the arms, and wake crying 
or fretting every few minutes or hours ; older children sleep uneasily, 
talk in their sleep, or start and cry out, and are often delirious. In some 
instances, the irritability is most distressing, both to the child and to those 
around. The child is constantly fretting and whining ; it wants its play- 
things, but will not touch them; food, but rejects it; and slaps and 
scolds at everything about it. Convulsions sometimes occur at the inva- 
sion. They last an uncertain length of time, and are usually followed by 
insensibility, from which the child wakes with fever, accelerated respira- 
tion and cough, indicating the true seat of disease to be the lungs, and 
not the brain, as might at first be supposed. I have met with but two 
cases attended with convulsions. One occurred in a boy between ten 
and eleven years of age, on the second day of the disease. The attack 
was induced more, however, by an unwholesome meal taken on the first 
day of his sickness, than by the mere effect of the local inflammation. 
In the other case, which occurred in a boy between five and six years old, 
there were two convulsive seizures, a violent one on the first day of the 
pneumonia, and a slighter one a few days later. The headache is some- 
times very severe; in a few instances I have known it to be so violent as 
to constitute the most prominent symptom of the case. On one occasion, 
indeed, it was so intense, and so much complained of, during the first two 
days of the fever, as to withdraw my attention from the true seat of 
disease, and it was not until the third day that I discovered the existence 
of pneumonia. The cough was in this, as in other instances, in which 
the nervous symptoms were strongly marked, so slight as to escape 
notice. 

Digestive Organs. — Complete anorexia is generally present from the 
first; the thirst is intense, greater, indeed, than in almost any other 
affection of childhood. The tongue is moist, as a general rule, and 
covered with a whitish or yellowish fur. Vomiting and diarrhoea occur 
at the invasion of about half the cases in hospitals : in private practice, 
vomiting often occurs, but diarrhoea much less frequently. 

Diagnosis. — The lobar pneumonia of children is most liable to be 

11 



162 PNEUMONIA. 

confounded with bronchitis, pleurisy, and hydrocephalus. There is little 
probability, however, that lobar pneumonia would be mistaken for 
bronchitis by any but a careless or incompetent observer ; for the pre- 
sence, in the former, of subcrepitant, and very often of crepitant rhon- 
chus, of bronchial respiration, bronchophony, resonance of the cry and 
cough, and dull or flat percussion, confined to one side, would easily 
distinguish it from bronchitis, which is marked by sibilant and mucous 
rales over both sides of the chest, and by a normal condition of the 
percussion. It is difficult and often impossible, as already stated, to 
detect the existence of partial pneumonia, at least to make the diagnosis 
with absolute certainty. The cause of the difficulty, as before explained, 
lies in the fact, that it presents, in a great many instances, no clear 
physical signs. When the number of inflamed nodules scattered through the 
healthy texture of the lung is small, and especially when they are deeply 
seated, no alteration whatever of the natural respiratory sounds can be 
perceived, and we are obliged to depend entirely upon the rational 
symptoms, — the accelerated breathing, oppression, pain, cough, fever, and 
the absence of the physical signs of other pulmonary inflammation. 
Sometimes the presence of the characteristic sputa of pneumonia will, in 
older children, make the diagnosis clear. When the inflamed nodules 
are situated near the surface of the lung, we may, in some instances, 
detect crepitant or fine subcrepitant rale and bronchial respiration, over 
circumscribed portions of the lung, and there would be, under such cir- 
cumstances, no hesitation as to the diagnosis. 

It has been stated that pneumonia might be confounded with pleurisy. 
This could not happen in regard to the partial form, as the slighter degree 
of the pain, the limited extent of the rale and bronchial respiration, and 
the absence of dulness on percussion in the latter, would prevent such a 
mistake. The distinction between pleurisy and the lobar form is more 
difficult, but may generally be made out by attention to the fact that pleu- 
risy is rare under six years of age ; by the greater severity of the pain, the 
absence of rhonchi, the effect of change of position on the sounds yielded 
by percussion, the shorter duration and greater mildness of the general 
symptoms, the entire absence or small amount of expectoration, and by 
the continued dryness of the cough in pleurisy ; and, lastly, by the dispo- 
sition on the part of pleurisy to become chronic, while pneumonia nearly 
always remains acute. 

Pneumonia in children not unfrequently simulates, in its early stage, 
an attack of meningitis. Vomiting, constipation, extreme irritability or 
restlessness, and complaints of headache, occur in both, while the absence 
of thoracic symptoms to draw attention to the true seat of the disease in 
pneumonia, may readily mislead. The cough in the early stage of pneu- 
monia is sometimes very slight, and not being observed by the attendants, 



DIAGNOSIS. 163 

is not reported to the physician. The frequency of the respiration is 
overlooked, or, if noticed, is ascribed to the fever, which is supposed to 
depend on the cerebral inflammation. In pneumonia, however, the 
vomiting is not usually very frequent, nor very obstinate, nor are the 
bowels so much constipated as in hydrocephalus. These variations from 
the ordinary symptoms of hydrocephalus, minute though they be, ought 
to attract the notice of the physician, and lead him to examine the case 
more carefully ; when, in all probability, the physical signs would imme- 
diately reveal the pneumonia. I may mention, in illustration, that I 
attended a boy six years old, who, for three days, suffered from violent 
fever and excruciating headache, which last was the only symptom com- 
plained of. There were neither cough, expectoration, nor any marked 
acceleration of the respiration. After three days the headache moderated, 
and he had slight pain in his side ; on examination, I found him laboring 
under well-marked lobar pneumonia. In April, 1847, 1 was called to see 
a boy nineteen months old, who had been taken sick with slight fever, a 
little hoarse cough, and mild pharyngitis. After remaining in this 
condition for five days, he began to be drowsy and very irritable, the 
surface became pale, and the extremities rather cooler than natural. 
From the sixth to the tenth day, there was great somnolence, the child 
sleeping nearly all the time ; when waked from sleep, he was always 
exceedingly irritable and cross, scarcely opening his eyes, and then shut- 
ting them again immediately to avoid the light, which was evidently 
painful. During this time he took scarcely any food, but little drink, 
and vomited several times freely ; the bowels were moved without medicine ; 
the surface remained very pale, and the extremities often cool; the pulse was 
frequent and small, the respiration perfectly regular, for which reason it 
attracted no attention, and there was no cough whatever. Under these 
circumstances, I hesitated between regarding the case as one of meningitis, 
or of hydrocephaloid disease, as described by Dr. M. Hall. I took the 
latter view, however, and treated it with small quantities of brandy, cold 
to the head, and the frequent employment of mustard pediluvia. From 
the eleventh day the child began to improve ; it would open its eyes from 
time to time, and look round for a few moments ; the face began to show 
a slight degree of color, and the palms of the hands, which had been 
white and transparent, exhibited a tinge of the natural pink hue which 
they have in children. Observing about this time that the respiration 
was accelerated, though perfectly free and regular, and without cough, I 
counted it, and was astonished to find it 80 in the minute. I now 
examined the chest carefully, and finding slight dulness on percussion 
with bronchial respiration, over the inferior half of the left side behind, 
immediately understood the nature of the case : it was one of latent 



164 PNEUMONIA. 

pneumonia, simulating hydrocephalus. The child was now treated for 
pneumonia, and after an illness of twenty-seven days longer, recovered 
perfectly. As the case progressed, the rational signs of pneumonia were 
more and more apparent, the cough becoming frequent and painful, and 
after a time loose, while the cerebral symptoms gradually disappeared. 

In addition to these cases, I have met with several others which, during 
the early stage, resembled very closely the invasion of cerebral disease. 
One of these has already been referred to in the account of the symptoms 
of the disease. Two others occurred in children within the year, and one 
in a child between one and two years old. Attention, however, to the 
rate of the respiration and the physical signs, and the presence of slight 
cough revealed, in two of them, after a little hesitation, the true character 
of the attacks. The third case, which occurred in one of the children within 
the year, was unattended by any cough during the first few days, and was, 
therefore, very obscure, until my attention was attracted by an accelera- 
tion of the respiration, when the physical signs, and at a later period, 
cough, explained the real nature of the attack. I may remark, in addi- 
tion, that in all these cases, the absence of constipation, the infrequency 
and short duration of the vomiting, and some clearness of the intelligence 
when the child was fairly roused, though but for a few moments, from 
its state of somnolence, were other motives for doubting the attacks to be 
meningitis. 

Dr. West states that pneumonia is often overlooked in teething children, 
in whom the cough is called a tooth-cough, whilst the diarrhoea, which 
frequently occurs, and becomes the prominent symptom, is supposed to 
depend upon dentition, and is alone attended to. The diarrhoea is obsti- 
nate, and when, at last, the cough attracts attention, it is ascribed to 
phthisis, and the physician is astonished to find at the autopsy purulent 
infiltration of the lungs, but no tubercles, and no disease of the intestines. 
The diagnosis is to be correctly made, under such circumstances, only by 
careful physical examination. 

Prognosis. — It may be stated in general terms, that pneumonia is the 
more dangerous in proportion as the child in whom it occurs is younger; 
and that the secondary, consecutive, or intercurrent form of the disease is 
much more dangerous than the primary. It is usually supposed to be 
almost necessarily fatal in new-born children, and to be very dangerous, 
though less so than in neonati, up to the sixth year of age. There has 
been so much confusion, however, in regard to atelectasis of the lung and 
true pneumonia until within a very few years past, that it is scarcely 
possible to trust to former statistics upon this point. From six years of 
age up to fifteen, the disease is almost always curable when of the primary 
form ; when of the secondary form the result is much more doubtful, and 



PROGNOSIS — TREATMENT. 165 

will depend in great measure, of course, on the nature of the disorder 
during or after which it occurs. 

The results of my own experience, which, it ought to be remarked, 
has been acquired almost exclusively in private practice amongst the 
easy classes of society, have been as follows : — of fifty cases of well- 
marked lobar pneumonia (thirty-seven observed during the last four years, 
and thirteen previously) only two were fatal. Of these two, one occurred 
in an infant six weeks old, and was accompanied with extensive and 
violent pleurisy, and the other occurred in a child between two and three 
years old, lasted thirty-three days, and was attended with considerable 
bronchitic inflammation. 

TVe may conclude, therefore, that pneumonia under two years of age is 
always dangerous, and much more so when secondary than when primary; 
that primary pneumonia, between the ages of two and five years, will 
terminate favorably in the great majority of cases in private practice; and 
that when the disease attacks children between six and fifteen years of age, 
the termination is nearly always in health. 

The following are some of the most unfavorable symptoms of the 
disease : convulsions ; small, weak pulse ; extreme rapidity of the respira- 
tion ; persistence of the bronchial respiration in young children ; incom- 
plete resolution of the disease within the ordinary period ; excessive and 
obstinate diarrhoea; severe cerebral symptoms; great emaciation; greatly 
altered physiognomy; excessive irritability; and a yellowish tint of the skin. 
M. Trousseau regards as an unfavorable symptom the occurrence of swell- 
ing of the veins of the hands, which he supposes to depend on an obstacle 
to the function of haamatosis. 

Treatment. — The treatment of pneumonia has been studied with the 
greatest care during the last several years. The researches of Louis, 
Grisolle, Rilliet and Barthez, and West, have given a completeness and 
certainty to this part of our subject, not possessed in regard to any other 
malady. I shall confine my remarks to the remedies which are now 
generally acknowledged to be most important, leaving those of doubtful 
value unnoticed. 

Bloodletting. — It is very generally conceded at the present time, 
that the loss of blood, whether by venesection, leeching, or cupping, exerts 
a more powerful influence upon pneumonia than any other remedy. Its 
effects are to relieve, and in some cases, to remove, with very great 
rapidity, the general symptoms. It reduces the frequency and force of 
the circulation, moderates the heat of the skin, calms the restlessness, and 
relieves the dyspnoea, thoracic pain, and headache. Is is very doubtful, 
however, whether it shortens the duration of the disease, or exerts much 
influence on the extent of the hepatization, — at least such is the conclu- 



1GG PNEUMONIA. 

sion of several of the French observers. Dr. West awards to it the first 
place in importance amongst the remedies for the disease, and, if it be 
restricted to a certain class of cases, I may say that I concur with him in 
opinion. These cases, however, have been but a minority of the whole in 
my own practice, though this has been exclusively private, and almost 
entirely confined to the easy and even wealthy families of the community. 
That it is not necessary in all, or nearly all, is shown by the fact that I 
made use of it only in sixteen out of thirty-nine primary cases in which 
the treatment was carefully noted, and in only two out of seven secondary 
cases, or in eighteen out of forty-six cases in all. Of these forty-six 
cases, two were fatal, in neither of which was it employed. One of these 
occurred in a child six weeks old, and was accompanied with very severe 
pleuritic inflammation; the other occurred in a child between two and 
three years old, and I have always regretted that I did not make use of 
depletion, in some form, early in the case. It appears, therefore, that all 
of the eighteen cases in which bloodletting was employed recovered, 
while of the twenty-eight cases in which it was not employed, two died. 
Of the two deaths, however, one occurred, as stated above, at six weeks 
of age, from severe pleuro-pneumonia, in which no other result could have 
been anticipated. This leaves twenty-six cases of recovery without de- 
pletion, enough to show, at least, that it is not essential in all cases. 

My opinion is, therefore, that depletion ought not to be employed indis- 
criminately in all children attacked with pneumonia, but that it should 
be restricted to a certain class of cases, — to those, in fact, occurring in 
hearty, vigorous subjects, of naturally good constitution, and of good present 
health. In weakly and debilitated children, it ought never to be used, or 
only with the greatest circumspection and moderation, and then as a general 
rule, only in the form of cupping. It ought to be employed with much hesi- 
tation in those born of feeble parents, in whom it may be supposed that 
there is but little stamina to go upon, and lastly, it may be said that when 
the physician doubts at all as to whether he should employ it or not, it is 
best to abstain. 

I know that there have been some attempts within a few years past, to 
show that pneumonia recovers as well, or almost as well, without as with 
bloodletting, but I cannot doubt the evidence of my own senses, and I 
have too often witnessed a very great and immediate mitigation of the 
symptoms, both general and local, of the disease, from a bleeding, leech- 
ing, or cupping, to be willing to abandon the use of these means, and trust 
the case entirely to its natural course. 

I have already referred to the fact that whilst the general symptoms 
are mitigated by bloodletting, the local disease is apt to run its usual 
course of several days. I once saw a boy, five years of age, with lobar 



TREATMENT. 167 

pneumonia of the left side, from whom eight ounces of blood had been 
taken by venesection and leeches, walking about the room apparently well, 
after a week's sickness, but in whom there was still present over the in- 
flamed lung, dulness on percussion, bronchial respiration, and crepitant 
rhonchus ; and I have had under my charge a girl four years of age, who, 
on the seventh day of the attack, after being leeched on the fifth, had a 
respiration of twenty, a pulse of ninety, and a cool natural skin, who was, 
in fact, entirely convalescent; in whom, nevertheless, there was dulness 
on percussion over the lower h'alf of the right lung, with bronchophony 
and bronchial respiration. 

The amount and manner of the depletion must depend on the age of the 
patient and the form of the pneumonia. It is usually recommended to make 
use of leeches and cups in children under two years of age, and of vene- 
section after that age. The quantity of blood to be drawn, must depend 
on the age and strength of the patient, and the violence of the attack. At 
the age of two or three years, and in idiopathic cases, about four ounces 
may be taken from the arm at once. Should this fail to produce some 
relief to the symptoms in twelve hours, the bleeding may be repeated, 
though this is very rarely necessary, in my opinion; or better still, some 
scarified cups or leeches may be applied over the seat of the disease. I 
feel quite sure that I have seen more benefit derived from cups than leeches 
under these circumstances, and would therefore prefer to use them where 
there is nothing to prevent. It is a common idea that scarified cups are 
too painful to be applied to young children, but this is not the case when 
they are properly selected. The cups should be much smaller than those 
used for adults, and the scarificator of a size to suit the cups. With these 
precautions, it will be found that the operation of cupping a child within 
the year, and still more from the age of a year upwards, is less annoying 
to the patient and more expeditious than that of leeching. I would, on 
these accounts, strongly advise country practitioners, who often complain 
of the difficulty or impossibility of procuring leeches, to provide them- 
selves with cups of a size suitable for children, to be used in the place of 
leeches. 4 > 

Whether leeches or cups be preferred after general bleeding, about two 
or three ounces of blood should be taken from over the inflamed portion 
of the lung. 

In children under two years of age, leeching, as has been stated, is 
generally preferred to venesection. I have not hesitated, however, to 
employ venesection in the course of the second year, when the symptoms 
have been very acute. The number of leeches should seldom exceed ten 
or twelve, which will commonly take about two ounces of blood. 

In cases of secondary pneumonia, depletion must be used with great 



168 PNEUMONIA. 

care, as this form of the disease has been found not to bear the loss of 
blood well. It is best, therefore, in most of these cases, to employ only 
local bleeding. 

To conclude my remarks upon the subject of bloodletting, I will merely 
state, in order that the reader may form his own judgment upon its re- 
sults in the cases above referred to, that venesection alone was employed 
in nine of the thirty-nine primary cases, and in one of the seven secondary 
cases, and that it was resorted to but once in each case; that both venesection 
and leeching were employed in one of the primary cases ; that leeches alone 
were made use of in three of the primary, and in one of the secondary 
cases j and, lastly, that wet cups were employed alone in three of the pri- 
mary, and in nine of the secondary cases. 

Antimony. — This remedy is well known to exert a powerful influence 
over pneumonia. Most writers agree in stating that it, like bloodletting, 
diminishes the force and frequency of the circulation, and relieves the 
oppression, but that, like bloodletting in this respect also, while mode- 
rating the constitutional symptoms and tending to keep them within safe 
limits, it fails to cut short or jugulate the inflammation. While writers 
agree, however, in regard to the effects of antimony in pneumonic inflam- 
mation, they differ very much as to the doses they recommend and 
the modes in which they administer it. I shall mention first the manner 
in which it is employed by two of the best European authorities in dis- 
eases of children, and then state my own opinions in regard to its proper 
mode of use. 

Dr. West (Loc. cit. 2d Ed. p. 217) prescribes it "in doses of one-eighth 
of a grain every ten minutes till vomiting is produced in the case of a 
child of two years old, and continued every hour or two hours afterwards 
for a period of twenty-four or thirty-six hours." He thinks that deple- 
tion either general or local ought almost always to precede its use in pure 
idiopathic pneumonia, while in cases preceded by bronchitic symptoms, 
depletion is not so important. The existence in any case of extensive or 
well-marked bronchial respiration, should be regarded, he thinks, as of 
itself contra-indicating the antimonial plan of treatment. It appears that 
Dr. West has been led, by a more extended experience, to lessen very 
materially the doses he makes use of, and this I am very glad to find, as 
it serves to confirm me in the opinion I have had for several years past, 
that the doses employed by the European physicians are much too large. 
In fact, Dr. West has reduced his doses, since the publication of his essay 
on pneumonia in 1843 {Brit, and For. Med. Rev., April, 1843), very 
nearly one-balf, and recommends the continuance of the remedy during 
one-half the length of time that he formerly thought necessary. His latter 
doses I have already cited. His former plan was to give it "in doses of 



TREATMENT. 169 

a quarter of a grain to a child of two years old, repeated every ten minutes 
till full vomiting is produced, and continued afterwards every two or three 
hours, for forty-eight or sixty hours. " 

MM. Eilliet and Barthez give to younger children, from two to four 
grains, and to those who are older, as much as six grains of the tartar- 
emetic, in solution, in the twenty-four hours. They administer the solu- 
tion in spoonful doses every half hour. If the first doses cause vomiting 
they are repeated less frequently. The quantity given on the first day is 
continued for the two, three, or four following days. They recommend 
caution, however, in the administration of the remedy, especially in very 
young children; and should it produce excessive vomiting or severe 
diarrhoea, advise its instant suspension. Should the state of the inflam- 
mation still require its administration, they employ it in very minute 
doses, and abandon it immediately should the intestinal symptoms return. 

For my own part, I am quite convinced, that the doses recommended 
by the writers quoted above, and by many others, are much too large, that 
they are entirely unnecessary, and that they must, in some instances, 
prove more or less injurious and even dangerous, for, though many 
children bear these doses without suffering, as shown by the experience of 
the writers referred to, there are many others, or at least there are many 
in this country, who would be injured by them. I have found, in fact, 
that when I attempted to make use of antimony in what I should call 
large doses, though they were still very small compared with those 
recommended by European authorities, it was sure to produce very un- 
pleasant symptoms in some, though not all the subjects. It caused in 
such a more or less persistent paleness, exhaustion, and rapidity and 
weakness of the pulse, attended sometimes with drowsiness alternating 
with irritability, depending apparently on prostration, and resembling the 
condition of shock, as described by Dr. Marshall Hall. That antimony 
often produces injurious effects on the economy is the opinion also of 
MM. Rilliet and Barthez, though they are amongst those who advocate large 
doses. They in fact state (Loc. cit. t. i. p. 467, 468) that " one of the 
chief causes of gastritis and softening of the stomach in children has been, 
according to our experience, the employment of energetic treatment 
directed upon the gastro-intestinal mucous membrane. We refer par- 
ticularly to the tartar emetic solution given for several days in succession. 
Though the doses were not carried to a great extent, and the quantity of 
the vehicle was ample, the disease has often occurred, thus proving the 
susceptibility of the mucous coat." They recommend great reserve in its 
use, " because two-thirds of the cases of gastritis that we have observed, 
and some of the cases of softening, followed the employment of that 
remedy." They remark afterwards, however, that the gastro-intestinal 



170 PNEUMONIA. 

lesions generally followed the exhibition of the antimonial in secondary, 
while it seldom occurred in idiopathic cases of the disease. 

I find it difficult to believe that children can take this remedy in the 
doses recommended by MM. Rilliet and Barthez and by Dr. West, without 
dangerous effects, since in my own practice doses of a twentieth or thir- 
tieth of a grain given every hour to children of two years old, are quite as 
much as they will bear without incessant nausea, and, in a great many, 
without the signs of severe prostration. Indeed, in some children of four 
and five years old, I have found that the thirtieth, fortieth, and even 
fiftieth of a grain, repeated every hour, caused more sickness, paleness, 
distress, and prostration, than I liked to see, and how such patients could 
have borne doses of an eighth, a quarter, or half a grain at a time, I am 
quite at a loss to understand. Moreover, I believe, as was stated above, 
that large doses are unnecessary, since I have been able to cure the disease 
with much smaller ones, and it is certainly best to avoid giving more of 
such a remedy as antimony than is absolutely requisite. 

My own practice has been to give the remedy after depletion, in doses 
of the thirtieth, fortieth, and even sixtieth parts of a grain every hour, to 
children of the age of two or three years, and even in this quantity it 
often produces vomiting or painful nausea. If the fever, oppression, and 
heat of skin, persist in the same degree after several doses, the quantity 
should be increased ; if, on the contrary, they subside, the doses ought to 
be diminished. In the cases of children over the age of three years, the 
dose must be increased according to circumstances. A very convenient 
and satisfactory mode of exhibiting antimony to children, is to give the 
vinum antimonii, combined with sweet spirits of nitre, in the doses of 
two, three, or four drops of the former, with eight or ten of the latter, re- 
peated every two hours; the proportions of the former to be increased or 
diminished as the stomach is found to tolerate it. To infants within the 
year, antimony ought to be given, it seems to me, with the very greatest 
caution. Many at that age do not tolerate well more than from half a 
drop to two drops of the wine, every two hours. Beyond that dose, it is 
very apt to produce exhausting nausea or diarrhoea. The use of the anti- 
mony ought to be persevered in until the acute symptoms have moderated, 
when it should be left off gradually. 

Before concluding my remarks upon antimony, it is proper to state that 
I am well aware of the fact that the doses recommended by the authors 
quoted above, and by many others of the highest authority, come at last 
to be tolerated by the stomach in a great many cases. I cannot but think, 
however, from personal experience, and from the evidence adduced by 
many observers in regard to the injurious effects of such doses upon the 



TREATMENT. 171 

stomach and intestines, in at least some of the cases, that we are scarcely 
justified in resorting to them, particularly as it has been found (by myself 
at least), that the disease is curable by smaller doses, in connexion with 
other means. 

Calomel. — I am induced to believe, from personal experience, that 
calomel is much less frequently required in the treatment of pneumonia, 
than was at one time very generally, and than is now, by a good many 
writers, supposed necessary. I have found a fair proportion (forty-eight 
out of fifty) of the cases that have come under my hands, recover with 
but an occasional and very moderate resort to it, and as I deem it a violent 
remedy that ought to be administered only when really called for, I have 
prescribed it much less frequently and in much smaller quantities than 
has been recommended by most authorities, and especially by the English. 

I have made use of it occasionally, however, under two conditions of 
things, — at the onset, when the febrile symptoms ran very high in strong, 
robust, and ruddy children, and during the course of the disease, when 
even small doses of antimony were not well borne, and when yet the 
severity of the reactional state seemed to require some strong and perma- 
nent sedative. In the former case, I have given one full dose of two or 
three grains, to procure the sedative and cathartic action of the drug, 
while in the latter I have employed it in small doses, in combination 
generally with nitrate of potassa, and, unless there has been some contra- 
indicating symptom, as drowsiness, or very sick stomach, with Dover's 
powder. 3Iy usual prescription for a child four or five years old is the 
following : 



R — Hydrarg. Chlor. Mitis, .... gr. iii. 

Pulv. Doveri, gr. iii vel vi. 

Potass. Xitrat gr. xxiv. — M. 

Ft, in Chart. No. xii. 



One of these is to be given every two hours. Should they occasion too 
much drowsiness after several have been taken, or produce distressing 
nausea, the dose is halved or suspended. I have seldom given more than 
six or eight, or at most the whole twelve of these powders. 

In some cases of pneumonia in hearty children, in whom, after bleeding 
and the use of tartar emetic for two or three days, the febrile symp- 
toms continued severe, in which the pulse was full and jerking, the 
skin very dry and hot, the countenance brightly flushed and looking as 
though glazed or varnished, the thirst acute, and in which there was a 
great deal of restlessness and distress from the acuteness of the fever, I 
have found much advantage from the following combination : 



172 PNEUMONIA. 

R — Hydrarg. Chlor. Mit., gr. iii. 

Antinion. Sulphuret. Prsecip., . . gr. ss. 

Pulv. Doveri, gr. vi. — M. 

Ft. in Chart. No. xii. 

Of these, one is to be given every two hours, until quiet is produced, when 
they should be suspended entirely, or given only once in four hours. 
Should they occasion vomiting, only half a powder must be given at a dose. 
MM. Rilliet and Barthez oppose the employment of calomel in secondary 
pneumonia as injurious, and in idiopathic cases as unnecessary, because in 
the latter form, the treatment by depletion and antimony has succeeded 
very well in their hands. Dr. West, on the contrary, awards high praise 
to it as a remedy after depletion ; but as he gave it combined with 
tartar emetic, I am disposed to ascribe a great part of the favorable effects 
of the treatment to the antimony. Dr. West also recommends it very 
strongly in cases of neglected pneumonia, after the time for depletion has 
gone by. In such cases its internal employment is often contra-indicated 
by the existence of diarrhoea ; under these conditions he uses it externally. 
In children of four years of age, he directs one drachm (of mercurial 
ointment I suppose), to be rubbed into the thighs or axilla every four 
hours. He says he has never known salivation to follow this plan, but 
has found the symptoms to diminish gradually in severity, and the solid 
lung to become once more permeable to air. Of the success of this plan 
of treatment. I have had no personal experience, as such cases are very 
rare in private practice. I would, however, under these circumstances, 
prefer the employment of the iodide of potassium, which I have found of 
great service in the chronic pulmonary complaints of children. From half 
a grain to a grain of that remedy, dissolved in compound syrup of sarsa- 
parilla, may be given three times a day, to a child three or four years 
old. 

Expectorants; Purgatives. — Ipecacuanha is preferable to the anti- 
monial preparations in the treatment of pneumonia under the following 
circumstances : when the disease occurs in infants within the year ; in 
children of highly nervous temperament, or of feeble and delicate consti- 
tutions ; in many cases of the secondary form ; in some of those in which 
bronchitis forms a prominent element of the attack ; in mild cases ; and 
lastly, in subjects who from idiosyncrasy do not bear antimony well, and 
there are many such. The most convenient preparation is the syrup, 
of which from ten to twenty drops may be given every two hours, at four 
years of age ; from five to ten drops, between one and three years ; and 
from one to three drops to infants of two or three months. It is useful to 
combine sweet spirits of nitre with the syrup, in doses to suit the age. 
In cases of pneumonia attended with bronchitis, when the child is much 



TREATMENT. 173 

oppressed by the presence of large quantities of mucus in the bronchia, 
the operation of an emetic is often highly beneficial. Ipecacuanha is the 
most suitable remedy under these circumstances, as it answers the indi- 
cation perfectly well, and produces less exhaustion and depression than 
any other. Either after or without the emetic, I have found decided 
benefit in such cases from the administration of decoction of seneka and 
spiritus Mindereri. For a child two years old I direct two drachms each 
of seneka and liquorice root to be boiled in a pint of water down to twelve 
ounces, and strained. A teaspoonful of this decoction is to be given every 
two hours, with twenty drops of the spiritus Mindereri. 

A purgative dose is useful at the beginning of the attack as a derivative 
and evacuant, but after that period, cathartic remedies need to be used 
only to such an extent as to keep the bowels soluble. It is scarcely 
necessary to say that when antimony is employed, especially in any con- 
siderable quantity, it almost always supersedes the necessity of purgative 
medication. The patient ought, however, to have a stool once a day or 
every second day. At first, a dose of castor oil, a moderate quantity of 
magnesia or syrup of rhubarb, is all-sufficient. In the after-treatment of 
the attack, a repetition of the same remedies in smaller quantity, or, what 
is often better, an occasional enema, is all that is necessary. Violent or 
frequently repeated doses of purgatives are injurious by exhausting the 
patient, or by setting up gastric or intestinal irritation. 

External Applications. — MM. Killiet and Barthez say that they have 
never found either blisters, or Burgundy pitch or tartar emetic plasters, 
exert the least influence upon any one Of the symptoms of pneumonia, but 
that, on the contrary, they increase the fever. Dr. West has been led to 
abandon the use of blisters entirely, in consequence of the irritation 
and fever they occasion, and the disposition to sloughing he has observed 
amongst the poor. I think I have observed great benefit in a few in- 
stances from the application of a blister, when depletion and antimony or 
ipecacuanha have failed to produce some moderation of the symptoms after 
four or five days. I have always been careful, however, even in children 
two or three years old, never to allow the blister to remain longer than 
an hour and a half or two hours. I direct it to be removed commonly in 
an hour and a half, whether the integument be blistered, of a scarlet 
color, or unchanged. A warm bread and milk poultice is then used as a 
dressing, and rarely fails to cause vesication in a few hours, if it have not 
already occurred. Many times I have been told by the mother that the 
skin was still white and unchanged beneath the blister when she removed 
it, and yet the poultice has produced full vesication. Treated in this way, 
blisters cause very little irritation, and I have never known but one to 



174 PNEUMONIA. 

slough in my life, and that happened in a child whose skin had been very 
much irritated by frictions with amber oil and ammonia. 

Since the spring of 1845, however, when I was led to make frequent 
use of mustard poultices and pediluvia in the treatment of the bronchitis 
and pneumonia of measles, I have rarely employed blisters, but have pre- 
ferred the employment several times a day of the remedies just indicated. 
Two parts of Indian meal and one of mustard, for young children, and for 
those who are older equal proportions, are to be mixed with warm water, 
and spread thickly like a poultice on a piece of flannel or rag five or six 
inches square. This is to be covered with fine muslin, linen, or gauze, 
and applied first over the back and then the front of the thorax. It may 
remain from fifteen to forty minutes, or until the child cries or complains, 
or until the skin is reddened. The mustard foot-baths may be employed 
at the same time with the poultices. These applications are useful 
whenever the oppression is very great, and, when resorted to in the 
evening, they often allay irritability and dispose the child to sleep. The 
number of applications to be made in a day must depend on the urgency 
of the symptoms. I have employed them from once a day to every two 
or three hours. 

Tonics and stimulants are to be resorted to in cases which manifest 
undoubted signs of debility. When, therefore, the attack occurs in a 
feeble child; when the inflammation remains unresolved after depletion 
and other remedies, and when extensive bronchial respiration persists, 
though the fever has moderated, attention must be paid to the state of the 
constitution, to the neglect of the local disease. The system must be 
sustained and strengthened, in order to give it time and power to carry on 
the operations necessary for the removal of the local obstruction. With 
this view, all depleting means should be abandoned, and the child put 
upon a nutritious diet and the use of tonics and stimulants. The diet 
may consist of preparations of milk, of soups, eggs, and small quantities 
of meat carefully prepared. The best stimulants are weak brandy and 
water, milk punch, wine whey, or wine whey and arrow-root water. The 
most suitable tonics are quinine and the preparations of iron. A grain of 
quinine, suspended in a mixture of equal parts of syrup of gum and 
syrup of ginger, and given three or four times a day, has succeeded best 
in my hands. 

Opiates are sometimes necessary in cases occurring in children of highly 
nervous and irritable temperament, in the secondary and cachectic forms 
of the disease, and whenever the cough is very frequent and harassing. 
After the acute symptoms have moderated a little, an evening dose of the 
Dover's powder, or a few drops of laudanum or paregoric, with sweet 
spirits of nitre, are often of great service. 



BRONCHITIS. 175 

General Management. — The diet ought to be very strict in idio- 
pathic cases. The child should have nothing for two or three days except 
demulcent drinks, or weak milk and water sweetened ; no solid food ought 
to be permitted. After the severity of the symptoms has moderated, pure 
milk, milk toast, or chicken water may be allowed ; and when all fever 
has disappeared, the usual food may be given, at first, however, in small 
quantity. A child at the breast ought not to nurse as freely as usual. 
At all ages, care should be taken to give water from time to time : very 
young children often suffer severely for want of attention to this point. 
I have seen the most violent and obstinate screaming in a child a year old, 
quieted at once by a copious draught of cold water. The patient should 
be kept strictly confined to a well-ventilated room, with the temperature 
as nearly as possible between 68° and 70° F. A direction given by some 
of the French writers, and by Dr. G-erhard, is not to allow very young 
children to lie for too long a time in one position in bed, or in the nurse's 
arms, as it is apt to produce a stasis of blood in the dependent portions of 
the lungs, and thus to maintain or increase the disease. Dr. West recom- 
mends, whenever the inflammation has reached an advanced stage, or 
involved a considerable extent of the lungs, that the patient be moved 
with great care and gentleness, lest, as he has often seen occur, convulsions 
be produced. 



ARTICLE III. 



RONC HITIS. 



Definition ; Synonymes; Frequency; Forms. — The term bron- 
chitis is now universally employed to express inflammation of the mucous 
membrane of the bronchia. 

It is usually called in this country catarrh, and catarrhal fever. It 
has been stated under the head of pneumonia, that many of the cases 
known amongst us by the popular term catarrh-fever, are, in fact, cases 
of pneumonia. I shall, on account of this misapplication of names, en- 
deavor to draw the distinction between bronchitis and pneumonia with 
great care. Bronchitis is not treated of either by Dewees or Underwood. 
Dr. Eberle confounds it with pneumonia under the titles of catarrh, 
catarrhal fever, acute bronchitis, and pleuritis. 

Bronchitis is one of the most frequent of the diseases of childhood. 
We have already seen that pneumonia causes a larger proportion of deaths 



176 



BRONCHITIS. 



amongst children in London, than any other disease except the exanthe- 
mata. Bronchitis causes a larger number of deaths in this city than any 
other disease of the respiratory organs, with the exception of pneumonia 
and croup. This is shown by the fact that during the five years from 
1844 to 1848, inclusive, there occurred in this city 18,599 deaths under 
fifteen years of age, from all causes. Of these, 613 were from bronchitis, 
756 from croup, and 772 from pneumonia. It is said to be more common 
as a secondary than as an idiopathic disease. Of 115 cases observed by 
Rilliet and Barthez, only 21 were idiopathic. Of 123 cases, however, 
that I have recorded, 76 were primary, and the remaining 47 secondary. 
The diseases during the course of which it is most apt to occur, are per- 
tussis and measles. 

I shall describe three forms of the disease : 1, acute bronchitis of 
moderate severity; 2, acute suffocative bronchitis, or catarrhus suffocati- 
ve, the congestive catarrhal fever described by Eberle and by Dr. Joseph 
Parrish of this city ; 3, subacute or chronic bronchitis. 

Causes. — Amongst the predisposing causes of the disease, age is one 
of the most important. Rilliet and Barthez suppose it to be much more 
common in children over, than in those under five years of age. Of one 
hundred and fifteen cases observed by them, thirty-seven occurred between 
the ages of one and five years, and seventy-eight between six and fifteen 
years of age. It is scarcely fair, however, to compare a period of nine 
years with oae of only four, as is done in the above statements. Of one 
hundred and twenty cases that I have seen in private practice, in which the 
age was noted, fifty-four occurred between birth and two years of age ; thirty- 
nine between two and four years ; twelve between four and six ; six between 
six and ten ; and three between ten and fifteen. Of eighty-one cases 
under four years of age, of which I have kept an accurate record, eleven 
occurred in the first half of the first year of life, twenty in the second 
half, making thirty-one for the first year; twenty-one occurred in the 
second year of life, nineteen in the third, and ten only in the fourth, 
showing that the liability is greatest in the first year of life, and particu- 
larly in the last half of that year, that it continues very strong in the 
second and third years, being nearly equal in each of these, and that it 
then suddenly diminishes. It would seem also that the simple acute, and 
the acute suffocative forms are most common under six years of age, 
while the secondary cases occur more frequently after that age. 

As to the influence of sex on the liability to the disease, it would appear 
from my experience to be rather more common in girls than boys, since of 
ninety-nine cases in which this point was noted, fifty-four occurred in 
girls, and forty-five in boys. The fact of its being more frequently a 
secondary than a primary affection, has already been noticed, though this 



CAUSES. 177 

has not been true of my experience. The diseases in which the largest 
number of cases occur are measles, pertussis, and typhoid fever. The 
secondary cases are most common, of course, during the prevalence of 
the diseases whose progress they complicate, whilst the primary cases 
are most common in the cold months of the year, and especially in the 
autumn and spring. Bronchitis is sometimes epidemic amongst children 
as it is amongst adults. 

The only exciting causes whose effects in the production of the disease 
seem clearly proved are sudden transitions from a warm into a cold 
atmosphere, and sometimes the contrary change \ prolonged exposure to 
cold, particularly when combined with moisture ; and the inspiration of 
irritating gases. I believe myself, from what I have seen in this city 
during the last eleven years, that the most fruitful cause of bronchitis, 
and also of pneumonia, croup, and angina in young children, is the style 
of dress almost universally used for young children. The dress is entirely 
insufficient. It consists usually of a small flannel shirt, cut very low in 
the neck, scarcely covering the shoulders, and without sleeves ; of a 
flannel petticoat, a muslin petticoat, and an outer dress made in nearly 
every case of cotton. The dress, like the flannel shirt, is cut low in the 
neck, is without sleeves, and fits very loosely about the chest, so that not 
only are the whole neck, the shoulders, and the arms exposed to the air, 
but, in consequence of the looseness of the dress about the neck, it is fair 
to say that the upper half of the thorax is also without covering. In the 
infant, from birth to the age of six or eight months, the dress is made 
long, a wise provision so far as it goes, but from the time the skirts are 
shortened, up to the age of four or five years in boys, when happily the 
time for boys' clothes arrives, and, throughout childhood in girls, the 
trunk of the body and the arms are dressed, or rather, left undressed, as 
above described. But, not only are the neck, breast, and arms left bare, 
but in many children the greater part of the legs are also kept uncovered, 
or, at least, short stockings, scarcely rising above the ankles, and muslin 
or sometimes Canton flannel drawers, not reaching, or scarcely reaching 
to the knees, leave exposed to the air a large proportion of the cutaneous 
surface of the lower extremities. Now, in this dress, the child passes the 
day in a house, the sitting-rooms of which are heated usually to 68° or 
70°, but in which the entries, and sometimes the parlors, are frequently 
at a temperature of 60°, 50°, or even lower, as I myself have tested with 
the thermometer. And not only are the entries and parlors, and indeed 
all the rooms, saving the one or two in constant use, frequently at the 
temperature just mentioned, but the air of the nursery itself is often al- 
lowed, through the negligence of the servants, and especially early in the 
morning, to fall to 60° or 58°, or possibly lower still. 

12 



178 BRONCHITIS. 






That this style of clothing is not correct, is proved by the simple facts 
that children, who are dressed nearly the same in summer as in winter, 
suffer scarcely at all from colds in the summer season, when the thermo- 
meter seldom ranges below 76°, and is usually above that point; and also 
by the fact, that adults have been driven by long and almost forgotten 
experience, to wear clothing twice or three times as warm as that which 
they put upon their children. How constantly do we see the strong and 
fully-developed man comfortably enveloped in a warm long-sleeved flannel 
shirt, woollen or thick cotton drawers, and cloth pantaloons, vest, and coat, 
in the same room, and in the same temperature, with the little, often puny, 
pale, and half-naked child. But it is almost impossible to make people 
understand that children need as much clothing as themselves. They 
always insist upon it, that as the child passes the greater part of the day 
in the house, it cannot require as much clothing as the adult who is 
obliged to go out and face the weather, forgetting, or refusing to see, that 
the former wears less than half, or probably not more than a fourth as 
much covering as the latter, and that the adult, when in the house and 
in the same rooms as the child, finds his one-half or three-fourths warmer 
clothing not at all superabundant or oppressive. 

I have repeatedly had patients to get well of chronic catarrhal and 
laryngeal coughs, and to cease to have, as before, frequent recurrences of 
these disorders, under the simple treatment of a long-sleeved and high- 
neeked merino or flannel shirt, long woollen stockings, and stout Canton 
flannel drawers coming down below tha knees, and that too, after the 
most patient and assiduous, and sometimes over-assiduous, trials of drugs, 
diet, and confinement to the house, had entirely failed of any permanent 
good effects. The fact is, that though there are some few children who 
can bear the dress above described without injury, there are a great many 
more who, while they wear it, either suffer all winter long from fre- 
quently-repeated attacks of cold, in the shape of croup, chronic laryngeal 
irritation with cough, chronic pharyngitis, bronchitis, acute or chronic, 
or more rarely pneumonia ; or, if they escape these direct effects resulting 
from the constant and rapid waste of their caloric, they are rendered more 
pale, thin, and delicate-looking than they would be were their vital forces 
husbanded by warm clothing, instead of being wasted in the constant 
struggle to keep up the heat of the uncovered body at the natural point. 

Anatomical Lesions. — I shall describe, first, the lesions met with in 
cases in which the disease is confined to the larger bronchia, the inflam- 
mation not extending into the capillary tubes, and next those observed in 
cases in which the disease has attacked the capillary bronchia; the 
former are those which constitute the form designated under the title of 
acute ordinary bronchitis of moderate severity, while the latter are those 



ANATOMICAL LESIONS. 179 

to which the term capillary has been applied. Patients seldom die of 
the first-named variety of the disease alone, but, as it often occurs as an 
accidental complication, or a more or less essential part of different severe 
and frequently fatal diseases, the morbid alterations which characterize it, 
have been very thoroughly studied and ascertained. 

The morbid alterations of acute ordinary bronchitis always exist in both 
lungs, and are confined to the larger bronchia, ceasing on a line with the 
smaller tubes and the capillary divisions. The most constant alteration 
is redness of the bronchial mucous membrane, caused by injection of the 
minute vessels of that and the subjacent tissues, and varying in shade 
from a rosy to a bright red or brownish tint. The mucous membrane is 
sometimes softened, a change which can be ascertained only in the 
largest tubes, and it sometimes presents a thickened, unequal, and rough 
appearance. Ulcerations are very rare. The inflamed bronchia contain 
a more or less abundant viscid, transparent, or opaque yellowish mucus. 

In capillar?/ bronchitis the alterations of the mucous membrane of the 
capillary tubes, do not always reveal the existence of the disease. That 
membrane is sometimes pale in the minute ramifications, and exhibits mor- 
bid changes only in those of medium size. The alterations of the membrane 
consist in redness, which is made up either of a number of fine points, 
seated in the membrane itself, or of arborizations seated both in the mem- 
brane and the cellular tissue beneath ; it sometimes presents a granulated 
appearance, and it may be more or less thickened, and its consistence 
diminished. The bronchia are usually filled and almost obliterated from 
the secondary divisions to the final ramifications, by a substance of a 
yellowish-white or yellow color, non-aerated, and composed of a thick 
muco-pus. Portions of false membrane are sometimes, not as a rule, but 
exceptionally, found mixed with the secretions just described, while, in 
other instances, false membranes alone are present in certain tubes. The 
false membrane may exist in the form of patches, or it may constitute a 
lining to the whole extent of the bronchial ramifications. It is usually 
soft, and but slightly adherent, and the mucous membrane beneath is 
either very pale and of its usual consistence, or red, softened, and rough. 
The different kinds of secretion are commonly most abundant in the 
bronchia of the inferior lobes. 

In a good many of the cases, another lesion, dilatation of the bronchia, 
is also found upon examination. This alteration evidently occurs under 
the influence of the inflammation ; it may affect either the length of the 
air-tubes, or only their extremities. In the former condition, the tube 
continues of the same size, or becomes gradually larger from one of its 
early subdivisions, until it reaches the surface of the lung ; in the latter 
condition, a section of the lung presents an areolar appearance, from the 



180 BRONCHITIS. 

presence of a multitude of little rounded cavities, communicating with 
each other, and with the bronchia, of which they seem to be a continua- 
tion. These cavities are generally central, though they are sometimes 
found upon the surface of the lung, in which case they are formed of the 
pleura, lined by the thinned membranes of the dilated bronchus. 

The fact of these cavities being true dilatations of the bronchia, has 
been called in question by Dr. Gairdner (Loc. cit. 7 p. 76), who believes, 
on the contrary, " that almost all the so-called bronchial dilatations, and all 
of those presenting the abrupt sacculated character here alluded to, are in 
fact the result of ulcerative excavations of the lung communicating with 
the bronchia." He supposes them to be the result of the expansion of 
certain small cavities, frequently met with in the bronchitis of children, 
and to be described directly under the title of vacuoles or bronchial 
abscesses, either by ulceration or by the act of inspiration. 

In addition to the lesions already described as existing in bronchitis, 
there is another one, not unfrequently met with, to which I shall call atten- 
tion, that to which the French writers apply the term vacuoles, and which 
Dr. Gairdner designates as bronchial abscess. The latter author states 
that in the centre of the collapsed lobules of a lung affected with acute 
bronchitis, there are found, not unfrequently, small collections of pus, 
varying in size from that of a hemp-seed to double or treble that 
volume. " These small abscesses present, on section, an appearance so 
much like that of softening tubercles, as to be very readily mistaken by 
many persons for these bodies ; and the resemblance is all the greater on 
account of the peculiar limited form of the condensation by which they are 
generally surrounded, which, when felt by the touch from the exterior of 
the lung, is exceedingly deceptive. In their interior, however, these little 
abscesses contain, in the recent state, a very fluid pus ; moreover, they are 
often met with as acute lesions produced by a few days of illness, and 
without a trace of tubercle in anyttther organ." When the pus is scraped 
or pressed out of these abscesses, in their recent form, they are found to be 
lined with a fine villous membrane, while in other instances they are not 
abruptly limited, but the pus appears to lie in contact with the surround- 
ing pulmonary tissue. The bronchia leading to the part of the lung thus 
affected, are found, when incised, to be much inflamed, their mucous mem- 
brane being vascular, thickened, and covered with pus ; and some of them 
can be observed to communicate with the purulent collections, the mucous 
membrane having been, at the point of communication, destroyed by ulce- 
ration, and either stopping short abruptly, or becoming gradually incorpo- 
rated with the false membrane lining the abscess. Sometimes these 
abscesses or vacuoles communicate not only with the bronchia, but also 
with each other, without difficulty; sometimes, according to Dr. Gairdner, 



ANATOMICAL LESIONS. 181 

they break into one another and form more considerable excavations, but, 
more commonly, they remain of limited size, preserving perfectly the 
direction and relations of the bronchial tubes. They occur both in the 
diffused and lobular form of condensation from collapse of the lung, and 
both forms may sometimes be seen in the same lung. 

The alteration just now described has excited a good deal of discussion 
amongst medical writers, and has been very differently accounted for. 
MM. Rilliet and Barthez regard it as a simple terminal dilatation of the 
bronchia, while MM. Barrier, and Legendre and Bailly, consider it to de- 
pend on a purulent breaking down of the vesicles 'of one or more lobules. 
MM. Hardy and Behier look upon it as a leston of a complex nature, par- 
taking both of dilatation of the bronchia and of pulmonary emphysema. 
Dr. Grairdner, as already mentioned, describes them as abscesses, and states 
that they " unquestionably arise from the accumulation of pus primarily 
in the extreme bronchial tubes of the collapsed lobules." This view, 
which is closely similar to that of MM. Barrier, and Legendre and Bailly, 
is, it appears to me, much the most reasonable that has been adduced. 

The parenchyma of the lung presents different appearances in different 
cases. It is supple, crepitant, and of a rose-gray color, but does not col- 
lapse, especially the anterior portions, when the thorax is opened, as does 
healthy lung. This imperfect collapse depends either on the fact that the 
thick mucus and muco-pus which fill and obstruct the bronchia, prevent 
the contained air from being expelled by the natural elasticity of the lung, 
or, when no secretions exist to produce this effect, on the loss of the natural 
elasticity of the organ. Another cause is the existence of vesicular emphy- 
sema, a lesion observed to a greater or less extent in nearly all the cases, 
and affecting usually the summit of the lung, its anterior edge, and also its 
posterior or lateral edge. In a large number of cases, and particularly in 
those occurring in young children and in weakly and debilitated subjects 
of all ages, the tissue surrounding the diseased bronchia exhibits the con- 
dition which has already been fully described in the article on atelectasis, 
under the title of collapse of the lung. The extent and mode of distribu- 
tion of this lesion, its peculiar and distinguishing characters, its causes and 
mode of production, and the method of treating it, have been carefully 
treated in the article just referred to, and I shall make no further allusion 
to it, in this place, except to beg the reader, who is not already fully 
acquainted with it in all its bearings, not to suppose himself master of the 
subject of bronchitis until he has also fully studied that of collapse, as the 
two go together so constantly, and the latter is practically so important, 
especially in children, as to make it essential for him to understand both. 

Chronic Bronchitis. — The lesions just described as characteristic of 
acute bronchitis, are also met with in the chronic disease. The dilatation 



182 BRONCHITIS. 

of the air-tubes, however, presents different features. The calibre of the 
enlarged tube is often much greater, its walls are whitish and uneven and 
cry under the scalpel, and beneath the mucous lining may be seen hyper- 
trophied transverse fibres. The mucous membrane itself remains smooth 
and polished, while the tissues beneath are thickened and hypertrophied. 

Symptoms; Course of the Disease; Duration. — Acute simple 
bronchitis exhibits very different degrees of severity in different cases, 
being in some extremely mild and benign, and in others so much more 
severe, as to border closely on the capillary form of the disease. In its 
mildest form, it occasions merely slight cough and stuffing, a little mucous 
rale over the larger bronchia, with a total absence of dyspnoea, or of decided 
fever. In cases rather more severe than this, it begins with a moderately 
frequent cough, which, dry at first, soon becomes loose, and is neither 
paroxysmal nor painful. The expression of the face remains natural, with 
• the exception of an appearance of slight languor. The pulse and respira- 
tion are but slightly accelerated; the external phenomena of the latter, an 
important means of diagnosis in infants, remain natural ; it occurs without 
jerking, the rhythm continues even and regular, and there is no violent 
action of the aloe nasi. The percussion is not modified. Auscultation 
reveals in very young children, a mixture of mucous and sibilant rales on 
both sides, which come and go, and are of short duration; in older children, 
the moist rales predominate, and commonly last several days. These 
sounds are seated in the larger bronchia. The temper of the child is not 
much changed ; the appetite is not entirely lost ; there is neither vomiting 
nor diarrhoea ; and the fever is usually slight. The disease remains nearly 
stationary, or increases for a variable length of time, after which the cough 
becomes looser, and in children over five years of age, is sometimes attended 
with expectoration of frothy or yellowish mucous sputa, whilst under that 
age there is no expectoration. The fever and other symptoms, with the 
exception of the cough, now subside; the cough remains some days 
longer. 

In attacks still more severe than this, the symptoms resemble very much 
those just now described, but they are all more intense. The cough is 
tighter, more frequent, harassing, and especially it is more painful, as 
shown by the fact that the child cries and complains, and that a marked 
expression of pain passes over the face at the instant of coughing. There 
is more fever, the skin being hot and dry, and the pulse more frequent, 
rising often to 130 or 140, and in one case to 156. The respiration is 
hurried, and though not attended with the same labor and anxiety as in 
the capillary variety, it is evidently oppressed ; it counted in three cases, 
60, 60, and 62. There is more restlessness, fretfulness, and general dis- 
tress ; the appetite is greatly diminished or lost, and infants nurse with 
less avidity than usual or refuse to nurse at all for several hours together. 



SYMPTOMS. 183 

In cases of this kind, the physical signs are more decided than in those 
of milder degree, there being a greater abundance of mucous and dry 
rales, and generally some subcrepitant rale, and they are heard over a 
larger extent of surface, usually over the lower half, two-thirds, or even the 
whole dorsum of the chest. The symptoms are almost always most marked 
and severe in the after part of the day and night. Yery often the patient 
will be comparatively easy and comfortable in the morning, but as the 
day goes on, he becomes more feverish, restless and fretful ; the cough 
grows more troublesome, more frequent, and tighter ; the breathing is 
quicker, and more oppressed ; the face is more flushed ; the sleep is broken 
and disturbed, and the child may appear through the night quite ill; and 
yet as morning approaches the symptoms moderate, the skin often softens 
and becomes moist, and the whole aspect of the case shows a great ame- 
lioration in the manifestations of the disease. 

The duration of this form of bronchitis is very uncertain ; the idiopathic 
cases last usually from four to seven or eight days, though they may last 
from sixteen to twenty-five ; the duration of the secondary cases depends, 
in great measure, on the nature of the diseases during which they occur. 

In any of these different degrees of acute simple bronchitis, the patient 
is liable, especially if it be a weak and debilitated child, or a young infant, 
to sudden and alarming aggravations of the symptoms. The breathing 
becomes suddenly either greatly increased in frequency, or excessively 
labored and oppressed, the surface becomes pale, the expression dull and 
languid, or distressed, the child is drowsy and inattentive, or uneasy and 
restless, the hands and feet are coolish, the act of sucking is performed 
with difficulty, or the child refuses the breast entirely, and it is evident 
that, from some sudden change in the condition of the lungs, the act of 
respiration and the aeration of the blood are very seriously interfered with. 
If this sudden aggravation of the symptoms be unattended with a corre- 
sponding increase of the febrile phenomena, as marked by greater heat of 
skin and augmented action of the circulation, it is altogether probable 
that it depends on a collapse of larger or smaller portions of the pulmonary 
texture, and if, on examination, we discover dulness on percussion, distant 
bronchial respiration, and cessation, or greatly diminished abundance of 
the bronchitic rales, over parts of the chest where a few hours or a day 
before there had existed all the physical signs of bronchitis, there can be 
no longer any doubt as to the cause of the suddenly increased severity of 
the symptoms, — it must be owing to collapse. 
' Acute suffocative bronchitis, capillar}/ bronchitis, or the congestive 
catarrhal fever of Parrish and Eberle, and suffocative catarrh, or bronchial 
croup of other writers, may succeed to the form just described, or appear 
as an idiopathic affection. Under either condition the general symptoms 



184 BRONCHITIS. 

are more threatening than in the preceding form, and the disease soon 
assumes all the appearances of great severity. The child is very uneasy 
and restless, constantly changing its position, moving about in the crib or 
bed, or insisting upon being changed from the bed to the lap, or from the 
lap to the bed. In one case that came under my charge, the oppression 
was very great, and the only position in which the child was at all satisfied 
was resting on the mother's arms, with the front of its chest applied 
against the mother's breast, and the head hanging over her shoulder. 
The expression of the face is anxious and disturbed, and its color usually 
pale or slightly bluish. The temper is irritable or subdued ; the child 
hates to be disturbed, and generally chooses its own position. The respi- 
ration is very much accelerated, running up in a very short time to 60, 
70, or 80, and it is usually more or less irregular, and evidently laborious 
and difficult. The cough is very frequent, troublesome, and evidently 
painful ; it occurs in short paroxysms usually, with or without stridulous 
sound, is at first dry, and after a few days, is accompanied in older children, 
by whitish or yellowish expectoration. In some instances, the sputa consist 
of mucus tinged with blood, or of pure blood even, and still more rarely 
of mucus mingled with small shreds of false membrane. The appetite is 
entirely lost ; the tongue is usually moist and furred white ; there is acute 
thirst, and yet, in severe cases, though the presence of acute thirst is evi- 
dent from the manner of the child, only very small quantities of water are 
taken, from the impossibility of suspending the respiration long enough 
to allow of more being swallowed ; the drink is gulped rapidly, suddenly, 
and with great difficulty, and after a time is refused almost entirely from 
this cause. In children old enough to talk, the speech is short and abrupt ; 
the patient dislikes to speak from the fact that the effort obliges it to sus- 
pend momentarily the act of breathing. Fever sets in from an early 
period j the skin is hot and dry, and the face is flushed at first, though it 
soon becomes pale in most cases, from the approach of an asphyctic state. 
The pulse becomes frequent, rising soon after the onset to 130, 140, 150, 
or higher ; it is full and hard early in the attack. The resonance on per- 
cussion is not modified. Auscultation reveals at first sibilant rale, mixed 
with some mucous rhonchus, but soon a fine subcrepitant rale is heard 
over all the lower parts of both lungs behind, and approaching, sometimes, 
over the bases of the lungs, the character of crepitus. After a time the 
subcrepitant rale is heard over the whole, or nearly the whole, of the 
dorsum of the chest, and to a greater or less extent, though not so well 
marked as behind, over the anterior regions of the thorax. This rale is 
audible at first both in inspiration and expiration, and is very distinct, 
but at a later period, it is heard only in the inspiration, or there is substi- 
tuted for it a mucous rale, while the subcrepitant rale is now heard only 



SYMPTOMS. 185 

in the forced inspirations during coughing or crying. These rales are 
fugitive and irregular, disappearing or changing from one to the other 
after fits of coughing. 

Should the case not take a favorable turn, which would be indicated 
by a moderation in the symptoms just detailed, and especially by 
easier and fuller respiration, with diminution of the amount of the sub- 
crepitant rale, and return of the natural respiratory murmur over some 
parts of the chest, the symptoms look still more alarming. The 
oppression becomes excessive ; fits of dyspnoea occur, in which the child 
is extremely restless and distressed, tossing itself about on the bed ; the 
respiration runs up to 80, 90, or more, in the minute, and is attended, 
with violent action of the alse nasi ; the pulse grows more and more fre- 
quent, rising to 150 or 160, and it loses force and volume; and the face 
assumes a whitish or slightly bluish tint, looks puffed, and is sometimes 
covered with perspiration. As the fatal termination approaches more 
nearly, the pulse becomes small, thready, and irregular; the respiration 
is uneven, irregular, stertorous, and often slower than before ; the cough 
is smothered and less frequent ; the restlessness generally diminishes, and 
the child sinks into quiet, and often becomes comatose ; the paroxysms of 
suffocation are less frequently renewed, and less violent, and death occurs 
in a state of quiet insensibility, or is preceded by partial or general con- 
vulsive movements. 

The duration of this form may be stated to be, on the average, between 
five and eight days. It may, however, end fatally in a much shorter time. 
In an example that I saw, in a child four months and a half old, death 
occurred in twenty-six hours from the onset. Dr. Eberle states that it 
seldom lasts longer than two or three days, and that in very young infants 
death sometimes occurs on the first day. M. Bouchut gives as the dura- 
tion in children at the breast, from two days to a week. Dr. West men- 
tions a case that proved fatal in less than forty-eight hours. In the fa- 
vorable cases that I have seen the duration was seven, eight, and ten 
days. 

Subacute and chronic bronchitis generally follows one of the acute 
forms of the disease. The character and severity of the symptoms vary 
very much in different cases. I have known some children to present 
for several months together, in the winter season, slight bronchitic symp- 
toms, consisting in wheezing and somewhat accelerated breathing, cough, 
more or less frequent, occasional feverishness, especially at night, some 
diminution of appetite, loss of flesh, and sibilant and sonorous, with 
mucous rales, heard here and there, but still no severe symptoms during 
the greater part of the time. Children laboring under this kind of bron- 
chitic irritation are liable to, and generally have, from time to time, more 



186 BRONCHITIS. 

or less sharp attacks of acute bronchitis, in which they present the usual 
symptoms of that form of the disease. These attacks are very apt to occur 
coincidently with changes in the weather, and in some patients the lia- 
bility to them is so great, from the excessive susceptibility of the system 
to the weather, that no care will prevent them. In some instances, I am 
very sure that an aggravation of the symptoms of the chronic form con- 
stantly occurs whenever the child is about cutting additional teeth, whilst 
in the intervals between the appearance of the successive teeth, the child 
remains comparatively well. I believe that the cause of the aggravation 
at the moment of cutting the teeth, is to be looked for, not in the act of 
dentition itself, but in the circumstance that the liability to cold is greatly 
increased at that particular moment, probably because the forces of the 
system are so weakened by the effort of the dentition, as to lessen the 
power of resistance against the disturbing influence of a changing, and 
particularly of a falling temperature. 

Cases of the mild kind of chronic bronchitis that I have just been 
describing, usually get well under proper medical, and especially under 
proper hygienic means, after several weeks or two or three months ; while 
in other instances, the disorder continues, in spite of every precaution, 
throughout the winter and spring, and only ceases as the warm summer 
months arrive. I have known the same disposition to show itself again 
in the following winter. In other instances again, the frequent attacks of 
severe bronchitis, together with the effect of a constant slight bronchitic 
inflammation, ends in the production of an emphysematous state of parts 
of the lung, and the child exhibits more or less marked asthmatic symp- 
toms, which show themselves whenever a slight increase of the bronchitis 
occurs, and whenever the digestive system is deranged from any impru- 
dence in diet or other causes. 

In other examples of chronic bronchitis the symptoms are much more 
severe. These cases almost always follow an acute attack of the disease. 
The frequency of the respiration, and the attacks of dyspnoea persist ; the 
cough is loose and paroxysmal, and the pulse frequent and small; evening 
exacerbations of fever take place, and the face and sometimes the rest of the 
surface, are often covered with perspiration. Auscultation reveals tubal 
blowing, with mucous or loud sonorous rhonchus, which seem to indicate 
the presence of dilatation of the bronchia. Emaciation makes rapid pro- 
gress, the face is pale and blanched, the eyes sunken, the nostrils are 
covered with mucous or bloody crusts, and the lips ulcerated. Strength 
diminishes progressively ; the appetite is lost, and the thirst acute ; col- 
liquative diarrhoea appears ; and after twenty, forty, or more days, the 
child perishes in the last stage of marasmus. This form of bronchitis 
often simulates phthisis very closely, and may last for a long time, even 



PARTICULAR SYMPTOMS. 187 

several years. It rarely occurs under the age of five years. The ex- 
pectoration consists of purulent or pseudo-membranous secretions in varia- 
ble quantity. 

Particular Symptoms. — Physical Signs. — The dry rales are 
amongst the most frequent alterations of the respiratory sound in bron- 
chitis. They may be sibilant or sonorous; they seldom exist alone, but 
are accompanied by mucous rale, and diminish as the latter becomes more 
abundant. As the dry rales cease to be heard, they are replaced by 
mucous or subcrepitant rale, or by feebleness of the respiratory murmur. 
The sibilant rale is often heard over the whole thorax, though it may be 
confined to the posterior portions. It is not restricted to cases of inflam- 
mation of the larger bronchia only, but is also present in capillary bron- 
chitis. 

Humid Redes. — Mucous and subcrepitant rale do not exist in all cases 
without exception, as they may be absent in such as are very mild. They 
may generally be heard on both sides behind, more rarely over the whole 
of the chest, and almost always both in inspiration and expiration. They 
are generally persistent, but are sometimes suspended for a moment, and 
replaced by sibilant rhonchus or feeble respiratory sound. Their duration 
is in proportion to that of the disease. 

Feeble respiratory murmur is sometimes observed. It is not perma- 
nent, occurs during the interruptions of the subcrepitant or sonorous rale, 
and does not occupy the whole extent of the thorax, but is limited ; it is 
intermittent, and is not accompanied by diminished sonoreity. 

When dilatation of the bronchia exists to a considerable extent, it gives 
rise to bronchial or even cavernous respiration, and to resonance of the 
voice, cry, and cough. The bronchial respiration differs from that of 
pneumonia by its tone, and by its intermitting. The percussion is gene- 
rally sonorous. 

It has already been stated in the account of the symptoms, that it 
happened not unfrequently in severe bronchitis, and also in mild bron- 
chitis occurring in debilitated children, that the respiratory sound sud- 
denly became feeble, or even entirely suppressed, over parts of the lung, 
while in other instances, a distant and imperfectly marked bronchial 
respiration takes the place of the natural vesicular murmur. These 
changes are heard either over small disseminated points of the lung, or 
over large surfaces ; they are associated with more or less evident dulness 
on percussion, and what particularly characterizes them, they are very 
fugitive, being present at one examination, and absent perhaps at the 
next. The appearance of these changes in the phenomena afforded by 
auscultation, were formerly thought to indicate the occurrence of pneu- 
monia, and especially of lobular pneumonia; they are now much more 



188 BRONCHITIS. 

satisfactorily explained by the supposition that they depend on diffused 
or lobular collapse of the tissue of the lungs. 

The physical symptoms above described are not invariably present in 
bronchitis. .Cases do occur, though they are very rare, in which auscul- 
tation fails to reveal the presence of the disease. 

Kational Symptoms. — The rational symptoms are of the utmost im- 
portance in informing us of the degree of severity of the attack. 

Cough generally exists from the beginning, being in mild cases more 
or less frequent, and either dry or loose, while in severe cases it is 
frequent or very frequent, at first dry and then moist, and very rarely 
hoarse. In acute capillary bronchitis, the cough has a particular cha- 
racter. From the first day it occurs in short paroxysms, lasting from a 
quarter to half a minute. The paroxysms vary greatly in violence, occur 
at irregular intervals, and generally continue without interruption to the 
fatal termination, though they are sometimes replaced by simple loose 
cough a few days before that event. The cough is rarely painful, so long 
as the inflammation remains simple. Expectoration is never present in 
very young children. When it occurs in those over five years of age, it 
consists, in the mild form, of a sero-mucous or of a frothy and yellowish 
mucous liquid. In general bronchitis it is sero-mucous at first, becoming 
after a few days yellowish and more or less viscous ; it is sometimes num- 
mular, and sometimes amorphous. 

The respiration varies in its characters according to the extent and 
violence of the disease. In mild cases, it is not much increased in fre- 
quency, being generally between 28 and 40 in the minute. In more 
violent cases, and particularly when the disease implicates the smaller 
bronchia, it becomes very frequent. The acceleration is slight in the 
beginning, but increases regularly as the case progresses ; thus it may be 
30 at first, and rise afterwards to 50, 60, 80, and even 90. When not 
very much quickened, it remains even and regular ; when more so, it 
becomes somewhat laborious, and the movements of the chest are full and 
ample ; in severe cases, attended with much dyspnoea, it is often irregu- 
lar, or assumes the characters to which M. Bouchut has applied the term 
expiratory, that is, the order of the movements is inverted, each respira- 
tion beginning with the expiration, leaving the pause between the inspi- 
ration and expiration, instead of between the expiration and inspiration. 
In chronic bronchitis with copious purulent or pseudo-membranous expec- 
toration, the dyspnoea is generally habitual. 

Fever. — The fever is slight in mild cases, the pulse rising very little 
above its natural standard. The heat is not great, and the febrile move- 
ment usually subsides before the termination of the disease. In the 
grave or capillary form, on the contrary, the pulse is always frequent, 



PARTICULAR SYMPTOMS. 189 

and continues to increase in rapidity as the disease advances. It varies 
between 104, 120, 160, and in very violent cases, rises as high as 200. 
Early in the attack, it is vibrating, rather full and regular, whilst in fatal 
cases, it always becomes small, irregular, trembling, and unequal. The 
skin is generally hot in proportion to the activity of the pulse, except 
towards the termination, when the extremities often become cool. It is 
almost always dry. In very young children it is often pale and cold, and 
covered with perspiration from the beginning. 

The expression of the face is unchanged in mild cases, but when the 
disease is violent and extensive, it becomes deeply altered after a few days. 
The eyes are then surrounded by bluish rings, and the expression is 
uneasy, anxious, and sometimes, but less frequently, exhibits an appear- 
ance of profound exhaustion. The anxiety of the countenance increases 
with the oppression ; the alge nasi are dilated, the nostrils dry or incrusted, 
and the lips and face, which are extremely pale or momentarily con- 
gested, assume a purple tint, particularly after the paroxysms of cough. 

The decubitus is ic different at first, but as the disease progresses the 
child lies with its thorax more or less elevated, or is restless and con- 
stantly changing its position. 

In dangerous cases there is great distress and restlessness after the first 
few days, or even from the beginning. In some instances the irritability 
and peevishness are excessive and uncontrollable, while in others, there 
is heaviness and somnolence, especially towards the termination of fatal 
cases. Some of the disorders of the nervous system just mentioned are 
present in all the grave cases. 

Digestive Organs. — There is moderate thirst and incomplete anorexia 
when the disease is mild, but, when severe, the thirst is generally acute, 
and the appetite entirely lost. The state of the bowels varies. The 
tongue and abdomen present no special characters in idiopathic cases. 

Diagnosis. — The mild form of bronchitis, in which the inflammation 
is confined to the larger bronchia, is not likely to be mistaken for any- 
thing but the early stage of hooping-cough. The diagnosis can be made 
only by attention to the different characters of the cough, which is more 
spasmodic and paroxysmal in pertussis, by the absence of fever in that 
disease, and by the development of the peculiar symptoms of each, as the 
case progresses. The diagnosis between bronchitis and pneumonia is 
seldom difficult, except when the latter is grafted upon the former, or in 
cases of partial pneumonia, attended with bronchitis. In well-marked 
cases of the two diseases, there can be no difficulty. The restriction of 
the physical signs to one side alone of the chest in pneumonia, the pecu- 
liar crepitus of that disease, or, when this is not heard, the fineness of 



190 BRONCHITIS. 

the subcrepitant rale, limited to the upper or lower regions of one lung, 
the bronchial respiration and bronchophony, the dulness on percussion 
over the seat of disease, the greater sharpness and severity of the pain, 
the more acute character of the febrile reaction, as marked by the pulse, 
skin, and thirst, and the kind of expectoration, when there is any, will 
always enable us to distinguish the two with almost absolute certainty. 
In cases, however, in which the two are combined, the diagnosis is not so 
easy, but even here the presence of dulness on percussion, and of crepitant 
or fine subcrepitant rale, or, when these are absent, of pure metallic 
bronchial respiration with bronchophony, over limited portions of the 
lung, will generally render the matter clear. 

The sudden supervention of dulness on percussion over large portions 
of one of the lobes of a lung, or over disseminated patches, with feeble or 
absent respiratory sound, or with muffled and distant bronchial respira- 
tion, generally indicates the occurrence of collapse in the part of the 
lung over which these signs exist; and when these symptoms show 
themselves without any increase in the severity of the febrile reaction, 
but rather with a diminution, there is every reason to suppose that they 
depend not upon inflammatory condensation of the parenchyma of the 
lung, but upon simple collapse from the presence of obstructive secretions 
in the bronchia. 

Dr. G-airdner (Loc. cit., p. 6) has called attention to a difference in 
the character of the dyspnoea in the two diseases, which is, I think, of 
considerable importance, and which I have often remarked myself. In 
bronchitis of any considerable severity, the respiration is always evidently 
laborious ; it is performed only with the aid of all the accessory muscles 
of respiration, and in really severe cases it is laborious, the inspiration 
being long-drawn, exhausting, and inadequate. The dyspnoea of pure 
pneumonia is, on the other hand, quite different. It is merely an 
" acceleration of the respiration, without any of the heaving or straining 
inspiration observed in bronchitis, or in cases where the two diseases are 
combined." Dr. Grairdner states that he has repeatedly seen patients 
affected with a great extent of pneumonia of both lungs, in whom the 
extreme lividity and rapid respiration, numbering 50 or 60 in the minute, 
showed infallibly the amount to which the function of the lung was inter- 
fered with, who, nevertheless, lay quietly in bed, breathing without 
any of the violent effort, or disposition to assume the erect posture, so 
constantly accompanying the more dangerous forms of bronchitis. In 
children these differences are even more marked than in adults. 

Chronic bronchitis may be mistaken for tuberculosis of the lungs or of 
the bronchial glands. The distinction can be made only by careful study 



PROGNOSIS — TREATMENT. 191 

of the history of the case, and of the phenomena afforded by auscultation 
and percussion. 

Prognosis. — Bronchitis is rarely a fatal disease, so long as it remains 
confined to the larger bronchia, constituting the acute simple form of 
moderate severity. Capillary bronchitis is, on the contrary, a very dan- 
gerous affection at all times, and at all ages. Even ordinary simple 
bronchitis, however, may prove fatal in young infants, and in debilitated 
children of all ages, from the supervention of collapse of portions of the 
pulmonary tissue j and it is necessary, therefore, that the prognosis given 
should always be guarded, when the disease occurs under either of these 
two conditions. The prognosis differs also in the primary and secondary 
forms of the disease, since, as might be expected, the danger is much 
greater in the latter than in the former variety. 

I have met with 123 cases of bronchitis, of which I have kept more or 
less copious notes. Of these, 108 were mild, and 15 capillary. Of the 
108 mild cases, 65 were primary, all of which recovered; and 43 secon- 
dary, of which 2 died. Of the 15 capillary cases, 11 were primary, of 
which 1 died, and 4 secondary, of which 2 died. Of the whole number, 
123 in all, 5 proved fatal. The danger from the disease depends very 
much, also, upon the hygienic conditions in which the patients are placed. 
In hospitals, and amongst the poor, it is much more dangerous than in 
private practice amongst the easy classes of society. This is shown by the 
fact that all the cases of the capillary form observed by MM. Rilliet and 
Barthez, and Fauvel, in hospital practice, proved fatal, while of 15 cases 
seen by myself in private practice, under the most favorable hygienic 
conditions, only 3 died. 

The symptoms indicating great danger are : increase of the dyspncea, 
extreme anxiety, small and irregular pulse, coolness or coldness of the 
skin with clammy sweats, much jactitation, and delirium, drowsiness, or 
coma. With such symptoms, the danger is greater and the fatal termi- 
nation more imminent in proportion as the child is younger, less robust, 
and its constitution exhausted by preceding or coincident disease. 

Treatment. — The acute simple disease requires, when mild, little 
other treatment than careful attention to the hygienic condition of the 
patient, and the administration of some mild expectorant. The child 
ought to be confined to an apartment with a well-regulated temperature, 
and it should be kept quiet, either in bed or on the lap. The clothing 
ought to be warm, and yet not sufficient to produce free perspiration, as 
this would expose to chilliness. The diet must be simple, and may con- 
sist of some of the preparations of milk with bread. As an expectorant, 
an occasional dose of syrup of ipecacuanha through the day, either alone, 
or if the cough be frequent and troublesome, combined with a little pare- 



192 BRONCHITIS. 

goric, laudanum, or solution of morphia, is proper and useful. The 
bowels ought to be moved once in the twenty-four hours, either naturally 
or by an enema. A warm foot-bath, with the addition of salt or mus- 
tard, in the evening, will generally assist to procure a quiet night. 

When, in the same form, the symptoms assume greater severity, when 
the signs of reaction are prominent, the dyspnoea considerable, and the 
cough frequent and harassing, it is sometimes, though but seldom, I 
believe, advisable to take a little blood. In children under three years of 
age, it is best, as a general rule, to make use of leeches, by which from 
one to two ounces of blood may be taken from the interscapular space ; in 
those over that age, from two to four ounces may be drawn in the same 
way, or by venesection. It seems to me, however, that a large majority of 
the cases of this form of bronchitis will do perfectly well without bloodlet- 
ting of any kind. A gentle purge ought to be given, unless the bowels 
have already been freely moved. This may consist of castor oil, rhubarb, 
magnesia, or what is a very convenient dose for children, half a teaspoon- 
ful of fluid extract of senna, mixed with a teaspoonful of spiced syrup of 
rhubarb. At the same time, some febrifuge and diaphoretic may be 
exhibited with much advantage. I am in the habit of using the anti- 
monial wine or syrup of ipecacuanha, combined with sweet spirits of nitre, 
as in cases of pneumonia. When the fever is considerable and the patient 
over a year old, the antimonial preparation is the best ; from one to two 
drops, with five drops of sweet nitre, may be. given every two hours. In 
some few older children and in young infants, half a drop only of the wine 
will be borne without nausea and exhaustion. If the ipecacuanha be pre- 
ferred, and it is generally most proper for children at the breast, the dose 
must be proportioned to the age, constitution, and present condition 
of the patient. 

If, as the case progresses, the bronchial secretions become very abun- 
dant and the dyspnoea severe, the proper remedy is an emetic. This may 
be ipecacuanha, either in powder or syrup, the syrupus scillse compositus, 
or a teaspoonful of powdered alum, to be repeated, if necessary, in ten or 
fifteen minutes. The latter substance is, as I have stated under the head 
of croup, a very certain, efficient, and safe emetic. 

Great benefit may be obtained in all forms of bronchitis, from the more 
or less frequent application of mustard poultices to the front or back of the 
thorax, and from mustard foot-baths. If the symptoms prove obstinate, a 
small blister over the sternum, or still better, the interscapular space, 
allowed to remain not more than one and a half or two hours, and then 
dressed with a poultice, is often very useful, though it should be avoided 
in young children as long as possible. 

The mercurial preparations, so much recommended by many of the 



TREATMENT. 193 

English and by some of our own writers, are, in my opinion, very seldom 
necessary in this, or indeed, in any of the forms of bronchitis in children. 

Killiet and Barthez recommend, when the cough and sibilant rale persist 
after the disappearance of the febrile symptoms, the use of small doses of 
the flowers of sulphur. I have myself known this remedy to prove of ser- 
vice in such cases. About four grains may be given every three hours to a 
child four years old. 

The grave acute or capillary form of the disease must be treated more 
actively than the preceding. While the pulse remains full and strong, 
the face flushed, and the skin hot, depletion is proper and necessary. The 
amount of blood to be taken must depend on the age, constitution, and 
present condition of the child : if over two years old, if of strong and robust 
appearance, and not reduced by preceding disease, from two to four ounces 
may be drawn from the arm. In younger children it is better, in most, 
though not in all cases, to employ leeches, taking within two ounces at a 
time as a common rule. I am in the habit of applying leeches, in the 
cases of children, to the interscapular space, as most convenient and mo3t 
effectual, because of its proximity to the roots of the lungs. After the 
child has recovered from the immediate effects of the bleeding, an emetic 
of ipecacuanha or alum may be administered with great benefit ; two hours 
after the emetic, small doses of antimonial wine and nitre, or fractional 
doses of tartar emetic should be prescribed, and repeated every hour or 
two hours. These doses should be, in my opinion, small. At two years 
of age, from one to two drops of antimonial wine, or a fortieth or even 
sixtieth of a grain of tartar emetic, given every hour or two hours, are 
quite sufficient. Should these doses cause repeated vomiting, or produce 
paleness of the skin, coolness of the extremities, or a languid, distressed, 
and anxious expression of the countenance, after being used for twelve or 
twenty-four hours, they ought either to be entirely dropped for a time, or 
else very much diminished, and of the two courses to be taken, I believe 
that the former is the safest. In connexion with these doses, counter-irri- 
tation to the surface of the chest will be found of very great service. 
Indeed, I doubt very much whether it is not the most important part of 
the treatment. It may be obtained by applications of dry cups to the back 
of the chest, or, if this be inconvenient or objected to for any cause, by the 
use of mustard poultices. The poultice ought to be about the size of the 
hand, or one half larger, and it should be made of one part mustard to two 
of Indian meal or flour. It is to be mixed with warm water, covered with 
book muslin or cambric, and applied first to the dorsum of the chest ; 
after having reddened at that point, it should be shifted to the front 
of the thorax. The time necessary for each contact is usually from ten 
to fifteen or twenty minutes. These applications ought to be renewed 

13 



194 BRONCHITIS. 

once in four hours, when the symptoms are only severe, but when these 
are urgent, they should be made every two hours. I am in the habit of 
depending very much, also, on mustard foot-baths. When the oppression 
is severe, and especially where there is any coolness of the extremities, the 
use of a foot-bath simultaneously with the mustard poultice, will often 
assist very much in relieving the breathing. 

In very young infants, antimony ought not to be employed, in my opi- 
nion, and in these, therefore, we need some other remedy. In them 
ipecacuanha is, I think, much safer than antimony, and it is quite 
active enough. The best preparation is the syrup, of which from three 
to five drops may be given every two hours to infants six months old. 
In older children also, in whom we have been obliged to suspend the anti- 
mony, and in those in whom its use has been contra-indicated by delicacy 
of constitution or by feeble health, the ipecacuanha is preferable. The 
doses must vary with the age. At five years, about ten drops every two 
hours, in combination with the same quantity of sweet spirits of nitre, is a 
proper dose. "When the child presents a pale surface and a languid ex- 
pression, and particularly when the skin is very slightly warmer than 
usual, or coolish, the following prescription has proved a most useful one 
in my hands : 



B. — Liq. Amnion. Acetat., 
Syrup. Ipecac, . . 
Liq. Morph. Sulphat., 
Syrup. Acacise, . . 

Aquas, 

Ft. Mistura. 



gss. 
gtt. xl. 

Si. 

giss. — M. 



The dose of this is a teaspoonful for a child two years old, to be re- 
peated every two hours. Should there be any nausea present, the syrup 
of ipecac, ought to be reduced to half the quantity ; and if there be any 
drowsiness, the morphia must be left out. 

In very severe cases of the disease, in which the dyspnoea is excessive, 
the pulse rapid and small, the skin cool and pale, the jactitation very 
great, and when there is present extensive mucous and subcrepitant rale, 
the treatment generally recommended is the frequent employment of eme- 
tics, and the French authors usually prefer tartar emetic. For my own 
part, I would not venture to administer, under such circumstances, so power- 
ful a remedy, and especially so potent a sedative, as antimony, one that I 
have often known to cause alarming and dangerous prostration in children 
laboring under much slighter disorders than suffocative bronchitis. If 
any emetic be given, it ought, it seems to me, to be one of milder action 
and less perturbing influence than tartar emetic, and I should choose 



TREATMENT. 195 

therefore, either ipecacuanha or alum. The plan of treatment that I 
prefer, however, is to make assiduous use of counter-irritants, and to give 
internally the spirits of Mindererus and decoction of seneka. Depletion 
is, in these cases, either entirely contra-indicated, or it should be resorted 
to only by the application of two or three small scarified cups. In a 
very severe case of this kind, the dangerous symptoms subsided under the 
use of cupping, mustard poultices and foot-baths frequently renewed, and 
the internal use of decoction of seneka and spiritus Mindereri every hour. 
Six small cups, of which only two were scarified, were applied once over the 
back of the thorax. In another case, which occurred in a child eighteen 
months old, during an attack of measles, the symptoms yielded and the 
eruption made its appearance, under the use of mustard foot-baths and 
poultices applied every two hours, and the internal use of spiritus Min- 
dereri and sweet spirits of nitre. In both cases, the symptoms of exhaustion 
were so strongly marked, that I feared to employ emetics, lest they might 
fatally increase the already dangerous prostration, though the dyspnoea and 
abundant mucous and subcrepitant rales seemed to call for them. 

In the bronchitis of children, it often becomes proper and necessary, in 
my opinion, to make use of stimulants. In the suffocative form, when the 
symptoms assume the character described in the last paragraph, small 
doses of brandy or wine-whey may be administered alternately with the 
spirits of Mindererus, with great advantage. In milder cases, also, when 
a sudden increase of the dyspnoea occurs, especially in feeble and debilitated 
subjects, and when we may suppose, from the character of the rational 
and physical signs, that collapse of portions of the lung has taken place, it 
is best to abandon for the time all nauseating remedies, and to make use 
simply of brandy in doses of from five to twenty drops every half hour or 
hour, or of wine-whey in dessert or tablespoonful doses, and of counter- 
irritants, with very light fluid nourishment. In such cases, the child 
ought to be laid on an inclined plane of pillows, and, with the exception 
of turning it gently towards one side or the other, from time to time, it 
should be kept perfectly quiet. These directions are particularly important 
in very young children, as it is in them that debility and exhaustion of 
the muscular forces are apt to bring about the state of collapse just re- 
ferred to. 

As an example of the kind of case in which stimulants are useful, 
and also as an example of the bad effects sometimes produced by 
antimony, I will quote the following : A girl between seven and eight 
years old, was attacked while in good health, with severe bronchitis. 
Qn the second day, when I was called, she was very much oppressed, the 
skin was hot and dry, the pulse rapid, and the surface pale. I ordered a 
cupping to the amount of four ounces, with some dry cups besides, over the 



196 BRONCHITIS. 

back, and two drops of antiinonial wine with ten drops of sweet spirits of 
nitre were to be given every two hours. On the third day a blister was 
applied over the sternum. On the fourth day I found the child in the 
afternoon very pale, dozing or tossing about on the bed, and sometimes 
rising up on her hands and knees with a bewildered look ; she was inatten- 
tive, so that it was almost impossible to catch her eye; the eyes were 
sunken, and the countenance was distressed and anxious; she moaned 
constantly and looked very ill ; the skin was still hot ; there was neither 
vomiting nor purging. The respiration was very much oppressed, and she 
coughed a good deal, though not so much as before. I suspended the anti- 
mony at once, and gave a teaspoonful of brandy in water, directing it to be 
repeated in three-quarters of an hour; after the second dose a teaspoonful 
was to be given in a wineglassful of milk and water every two hours 
throughout the night. On the following morning, the child looked better; 
she was less pale, and the eyes were not so excavated. The breathing 
was better. She was still very drowsy, but often waked partially with 
screaming and affright, and when awake took very little notice. The milk 
and brandy were continued every two hours. On the afternoon of this day, 
all the unpleasant symptoms had disappeared; there remained only those 
indicative of a slight bronchitis, and she was soon quite well. Now it 
seems to me exceedingly clear that, had the antimony been continued in 
this case, on account of the hot, dry skin, oppressed breathing, frequent 
cough, and from the absence of vomiting or purging, the child would 
have died. 

Chronic Bronchitis. — The most important points in the treatment of 
chronic cases are to insist upon a rigorous and persevering regulation of the 
hygienic conditions of the patient, and to make use of tonic, balsamic, and 
expectorant remedies. The child should be carefully and warmly clothed. 
This, indeed, constitutes in most cases the truly important part of the 
treatment, for without it, there is but little chance that drugs of any or of 
all kinds, diet, or any other measures, will be of any real service. The 
dress ought to be the first thing attended to, and after it and as a secondary 
matter, certain medical substances will assist in removing the disease. 
The child ought to be taken as often as possible into the air in fine weather, 
and only in fine weather. The diet should be selected with a strict 
view to the improvement of the strength and vigor of the constitution ; 
the food may consist, if the child be of proper age, of light meats, of 
potatoes and rice, as the only vegetables, and unless there is some contra- 
indicating circumstance, of a small quantity of wine, with the mid-day 
meal. The best wine is port, of which one or two tablespoonfuls may be 
given in a considerable quantity of water. 

Tonics must be administered throughout the course of the disease, or 



PLEURISY. 197 

until the appetite and strength shall have improved to such an extent as 
to make them no longer necessary. The best is probably quinine, in the 
dose of a grain morning and evening, to be continued for several weeks ; 
or the citrate of iron and quinine in the dose of half a grain or a grain 
three times a day, or from one to three drops of the solution of iodide of 
iron, used in the same way, may be substituted. 

In one case of chronic bronchitis, which came under my care, the 
patient recovered under careful regulation of the hygiene, and the use of 
a decoction of seneka prepared by boiling a drachm each of seneka and 
liquorice roots, in a pint of water, to half a pint. The decoction was 
strained, and a large teaspoonful given three times a day. The remedy 
was continued during a period of two months ; under its use the child grew 
fat and strong, and recovered entirely from the disease. 

Other remedies, proposed by different authors, are the various resinous 
preparations; the balsams of tolu and copaiba; benzoin; and the sul- 
phurous mineral waters. While these means are employed, it is recom- 
mended also to make use of counter-irritants. If any are used they ought 
to be such as will not produce too much inflammation of the skin, as for 
instance weak Burgundy pitch plasters, daily frictions with hartshorn and 
sweet oil, a simple diachylon plaster, or very mild pustulation with 
croton oil. 



ARTICLE IV. 



PLEURISY. 



Definition; Frequency; Forms. — Pleurisy consists in inflamma- 
tion of the pleural serous membrane. 

Idiopathic pleurisy is a rare disease under five years of age, and espe- 
cially in the first and second years of life. After the age of five years it 
becomes more frequent. I have met with 16 cases of pleurisy, of which I 
have kept notes. Of the 16, 14 were idiopathic, and 2 secondary, one of 
the latter occurring during hooping-cough, and the other being accom- 
panied by pneumonia, though the pleurisy was the predominant disease. 
Secondary pleurisy, on the contrary, or that which occurs in the course of 
other diseases, is common at all ages. M. Bouchut met with it in 23 out 
of 68 autopsies of new-born and suckling children. Of the 23, 9 accom- 
panied acute pneumonia, 6 tubercular pneumonia, 5 entero-colitis, and 3 
different other diseases. This form of the affection is rarely detected 
during life, being masked by the concomitant malady. 

I shall describe two forms of the disease, the acute and chronic. 



198 PLEURISY. 

Predisposing Causes. — As to the influence of age, it lias already been 
stated that idiopathic pleurisy is very rare between birth and five years of 
age. It is certainly rare during those years in comparison with pneu- 
monia, and especially with bronchitis, for I find that while I have met 
with but 10 cases of pleurisy of all kinds under 5 years of age, I have 
seen 19 of pneumonia under that age, and 105 of bronchitis under 6 years 
of age. Of 16 cases of pleurisy that I have seen, 14 were idiopathic, and 
of these one occurred between 1 and 2 years of age ; 2 between 3 and 4, 
5 between 4 and 5 ; 2 between 6 and 7; 3 between 7 and 8 ; and 1 between 
13 and 14. Of the two secondary cases, one occurred at six weeks of age, 
and one between 4 and 5 years. Secondary pleurisy is said, by the best 
authorities, to be most frequent between one and five years of age, being, 
in this respect, just the contrary of the idiopathic form of the disease. 

Pleurisy is said to occur more frequently in boys than girls. Of 15 
cases in which I noted the sex, 10 occurred in boys and 5 in girls. The 
idiopathic form is most apt to occur in vigorous and hearty subjects, while 
the chronic and cachectic forms attack those who are feeble and delicate. 
It is often, as already stated, a secondary affection, occurring particularly 
during pneumonia, and after that disease, during rheumatism, scarlet 
fever, and Bright's disease. Season is another predisposing cause. It is 
most common during winter and spring, especially the latter. 

The exciting causes are very obscure in most cases. The only ones 
which seem to have been ascertained with any certainty, are exposure to 
cold and to sudden changes of weather. It has been said to follow external 
violence. In one of the cases that came under my observation, the child 
had struck the affected side severely against a pointed stick on the day of 
the attack. 

Anatomical Lesions. — The serous membrane may retain its natural 
characters, which happens in the majority of cases, or it may present the 
different appearances indicative of inflammation. These are more or less 
minute and abundant injection and punctuation, and spots or patches of an 
ecchymotic appearance, observable particularly at the points where deposits 
of false membrane have taken place. Another change produced in the 
pleura by inflammation is the loss of its natural polish, which is replaced 
by a more or less granular and rough appearance. In chronic cases it 
becomes whitish or opaline in color, and thickened. It is very rarely 
softened. 

In addition to the lesions of the pleura itself there are various diseased 
products of secretion which require notice. These may be either solid or 
liquid. The solid products are the false membranes which exist so gene- 
rally in all serous inflammations. They are found both upon the costal 
and pulmonic pleura. In their recent state they are of variable size and 



ANATOMICAL LESIONS. 199 

thickness, being in some cases very soft and deposited in small points ; in 
others, more extensive, but thin like paper; and in others again thicker 
(one or two lines in thickness), firmer, and decomposable into several 
layers. The outer layers are yellow, elastic, and soft, while the inner ones 
are red, more resisting, and marked with vascular arborizations. When 
examined some time after their formation, the false membranes are found 
to have been converted into cellular adhesions, which may be either very 
loose, or they may fasten the lung tightly to the costal pleura. The adhesions 
are generally, however, thin, transparent, and in the form of loose bridles. 
After a length of time, the false membranes come to present the appear- 
ances of true serous tissue, and like that, are susceptible of inflammation. 

The fluid found in the pleural cavity usually consists of transparent or 
turbid serum, holding albuminous flocculi in suspension. Sometimes, but 
more rarely, it consists of purulent serum, and still more rarely of pure 
pus. The liquid generally occupies the lowest portion of the thoracic 
cavity, but is sometimes circumscribed at various heights, or between the 
lobes of the lung, by abnormal adhesions, or by some part of the lung 
which has been rendered incompressible by inflammation. 

The lung presents various alterations from its healthy condition. It is 
pressed backwards towards its root to a greater or less extent. The tissue 
of the organ is generally found in one of two conditions : either hard, not 
crepitating, impenetrable to the finger, and presenting a smooth surface 
when cut into, a state of things which has been expressed by the term 
carnification, and which is a mechanical effect of pressure ; or else the 
lower lobe, which is in contact with the fluid, is large, heavy, fleshy, rather 
hard, not so easily penetrable by the finger as in simple hepatization, 
yielding under pressure only a small quantity of blood, and but slightly 
retracted towards the spinal column. The latter condition, depends in all 
probability on an effusion which has occurred after, or coincidentally with, 
hepatization. 

In some cases, in which the effusion is but small, or where it has been 
absorbed, the lung is found to be elastic and crepitating. Whatever the 
amount of effusion may be, it is said that the lung can always expand to 
its normal size if the fluid be absorbed. 

Pleurisy, whether complicated with pulmonic disease or not, is much 
the most frequently confined to one side. In idiopathic cases, it is more 
common on the right than left side ; when it accompanies pneumonia, it is, 
on the contrary, more common on the left than right. 

Symptoms. — In describing the symptoms, I shall treat first of the 
physical, and then of the rational signs, and of the course of the disease. 

The physical signs are exceedingly important, as they often constitute, 
especially in young children, the only means of recognising the disease. 



200 PLEURISY. 

The pleural friction sound is less important than some other physical 
signs, as it is scarcely ever heard in children under five years of age, and 
only during the absorption of the fluid, as a general rule, in those above 
that age. Bronchial respiration may commonly be detected from an early 
period in the attack. At first it is heard during inspiration, but after- 
wards it exists both during inspiration and expiration, or in the former 
alone. In a majority of the cases it is heard over the posterior portion of 
the thorax, and upon one side only. At first it is audible over nearly the 
whole height of the affected side, while later in the disease, it can be per- 
ceived only at the inferior angle of the scapula or in the interscapular 
space. Its duration is variable ; it may disappear in a few days, or last for 
a much longer time. In favorable cases it is usually replaced by feeble 
vesicular respiration, more rarely by friction sound, and sometimes by pure 
respiration. This sign is almost always present at all ages in acute cases, 
but is often absent in those which are slow and tedious. In suckling 
children it is not constant, but intermits occasionally, so that it may be 
heard at one and not at the next examination. JEgophony can rarely be 
detected in children less than two years old. Under that age, there is 
heard instead of it resonance of the cry, especially in the region beneath 
and on a line with the spine of the scapula. It is intermitting like the 
bronchial respiration. In children over two years old, segophony can often 
be distinguished by careful examination, but never, of course, unless the 
quantity of effusion is considerable. It is heard at an early period of the 
attack, and chiefly in acute cases, and must be sought for in the lower 
portion of the interscapular space, and the inferior dorsal region. It 
coexists almost invariably with bronchial respiration, lasts but a short 
time, disappearing after one, two, three, or four days, and is intermitting. 
In older children, it is sometimes replaced by diffuse resonance of the 
voice, as it is by resonance of the cry in infants. In one case that occurred 
to myself, in a girl between six and seven years old, and in which the 
disease became chronic, the voice was not purely segophonic, but reedy 
and quavering, from the fifth to the tenth day. After that date the effu- 
sion became so great that all sound was suppressed. 

Feebleness or absence of the respiratory murmur seldom exists at the 
beginning of acute cases, but in the subacute or chronic form is generally 
present from the invasion. In the latter class of cases feeble respiration 
is noticed first over the inferior portion of the dorsal region, but, as the 
effusion increases, it is heard also in the upper and anterior regions, and 
becomes more and more feeble, until at length no sound whatever is audi- 
ble : the respiratory murmur is suppressed. In acute cases, on the con- 
trary, the absence of the respiratory sound is observed at variable periods 
of the attack ; when soon after the invasion, it is generally coincident 



SYMPTOMS. 201 

with bronchial respiration, which, heard at first over the whole or the 
inferior three-fourths of the dorsal region, becomes afterwards perceptible 
only in the interscapular space, or at the inferior angle of the scapula, 
while the respiration is feeble or absent over the lower portions of the 
lung. In acute cases the feeble respiration remains limited to the dorsal 
region, and disappears after a few days, — in from five to eight, according 
to my experience ; while in chronic cases it extends over a larger surface, 
and continues for several weeks, or even months. 

Percussion. — This means of diagnosis is very important in all cases of 
the disease accompanied by effusion of liquid, unless the quantity be 
exceedingly small. When, on the contrary, the inflammation results 
merely in the production of thin false membranes, percussion furnishes 
no useful information. 

Percussion is of no assistance, however, at the moment of invasion, as 
it is not until the period at which effusion takes place, that the resonance 
of the thorax begins to be altered. In acute cases, the resonance is 
generally duller than natural, though seldom entirely dull, on the second, 
third, or fourth day. As the effusion augments, the dulness increases 
over the region occupied by the fluid, until at length all resonance ceases, 
and the sound is perfectly flat. The degree of dulness can be properly 
appreciated only by comparing the two sides together. The degree, 
extent, and duration of this sign will depend of course upon that of the 
effusion. In children as in adults, the sounds afforded by percussion 
vary with the position of the patient, which influences, of course, the situa- 
tion of the fluid in the pleural cavity. 

In regard to the physical signs of pleuro-pneumonia, it may be stated 
that when a pleuritic effusion takes place in a child laboring under pneu- 
monia, it happens as a general rule, that the bronchial respiration occa- 
sioned by the inflammation of the lung increases in intensity, though in 
some few cases it is diminished or suppressed. Rilliet and Barthez lay 
down the following principle : " that when a pleuritic effusion occurs in a 
child affected with hepatization of the inferior portion of the lung, all the 
abnormal sounds which were perceptible over the diseased point are con- 
siderably exaggerated, and the sonoreity disappears." 

Inspection of the thorax affords no assistance at the invasion of the 
disease, nor generally in acute cases which last but a short time, and in 
which the amount of effusion is small. When, however, the effusion is 
large, it may be observed upon close examination, that the movements of 
the affected side during respiration are more limited than those of the 
opposite one, and that the intercostal spaces are more projecting than 
natural, in consequence of distension by the fluid within. At the same 
time mensuration will show that the side on which the effusion exists is 



202 PLEURISY. 

larger than the other. The difference may amount to one-third or two- 
thirds of an inch. In acute cases, in which the quantity of liquid is 
small, mensuration will of course show no difference. When the effusion 
is large, palpation is a very important sign. The hand applied over the 
diseased side feels no vibration of its walls either during respiration, 
crying, or speaking. This sign exists in infants as well as in older chil- 
dren. . 

Rational Symptoms ; Course ; Duration. — Acute pleurisy is rarely 
met with, as already stated, in children under six years of age, except as 
a secondary affection. In idiopathic cases it begins with severe pain in 
the side, cough, some difficulty of respiration, increased frequency of the 
pulse, loss of appetite, thirst, bilious vomiting, sometimes headache, and 
in rare instances delirium. The pain in the side or stitch, is almost always 
present in acute cases occurring in healthy children, while in those which 
are slight, or which occur in weak and debilitated subjects, or very young 
children, it very often cannot be detected. Sometimes, however, its exist- 
ence may be ascertained in very young children by tenderness of the side 
shown during the act of percussion. When present in young children, it 
can always be detected by watching the face of the child and observing 
its gestures, during the act of coughing, and during full inspirations, 
as in those made in crying, after sudden movement, or in the act of 
gaping. In an infant of thirteen months old, who was attacked with 
pleurisy of the right side, causing effusion of thick yellow pus into the 
right side, and which ended fatally in a month, only the blindest could 
fail to see that every act of coughing was acutely painful, for the child 
uttered each time a short, sudden cry, which was hushed as soon as given, 
while at the same moment there passed across the face an expression, 
amounting almost to a grimace, of suffering, which was unmistakeable. 
The pain is aggravated by coughing, by full inspirations, by change of 
position, and by percussion. The seat of pain is almost always in front, 
but it may extend irregularly over the whole of one side, or be confined 
to the false ribs, or less frequently to the neighborhood of the nipple ; it 
generally lasts from three to six days, though it sometimes continues 
longer. This symptom was complained of in most of the cases' that I 
have seen. In some it was very acute and severe for one or two days, 
while in others it was slight, not well defined, and very transitory. In 
one, the child said there was no pain, but a sensation of weakness in the 
side, when she coughed. In another the pain was severe for a few hours, 
but was relieved by a sinapism, and was not felt again, though the attack 
resulted in a very large effusion into the side. In a third it lasted a 
week, and in a fourth, only two days, though in both the effusion was 
extensive, and required several weeks for its absorption. In a fifth case, 



SYMPTOMS. 203 

it continued for five days. In the last, the effusion was very slight. It 
was aggravated in all these cases by coughing, by the act of respiration, 
especially when this was deep, and by motion. 

Cough exists in nearly all idiopathic cases, and generally from the 
onset, though sometimes not before the second or third day. Usually 
frequent and dry, it commonly retains these characters in acute cases, for 
four or six days, and then diminishes rapidly. In more tedious cases it 
continues for a longer time, but moderates in violence after some days. 
In secondary cases it has no special characters. It was present in all the 
cases seen by myself but one. Its character varied very much. In some 
it was frequent, teasing, and very painful. In others it was rare, scarcely 
troublesome, and only slightly painful. In all it was very dry, this con- 
stituting one of its most marked features, and giving it a very different 
character from the cough of bronchitis, and also, though somewhat less 
distinctively, from that of pneumonia. It continued almost entirely 
dry throughout the disease, except in a case which became complicated 
after a time with slight bronchial inflammation, and, in that, it became 
loose. There is generally no expectoration ; if any, it consists of a small 
amount of whitish, frothy, sero-mucous fluid. 

The respiration is usually accelerated in acute cases, but remains natu- 
ral in other respects ; the dyspnoea, however, is slight, as a general rule, 
compared with that of pneumonia. The difficulty of breathing is com- 
monly in proportion to the earliness of the age, and to the extent and 
rapidity with which the effusion takes place. In the acute cases that 
came under my own observation, the breathing was usually about 36, 38, 
40, and 48, but in one case it rose to 68 for a single day. It was not 
labored, and appeared to be difficult only from the fact of its being more 
or less painful. In the cases attended with but slight pain, there was no 
dyspnoea. It usually subsided after two or three days, when large effu- 
sion took place, converting the case into the chronic form. 

The fever is not usually very great, and seldom lasts more than a few 
days, or a week. In some few cases, however, that I have seen, the 
febrile reaction has been very high. In one, in a child between three and 
four years old, the pulse rose to 172 on the first day, though the respira- 
tion was but 36 ; the skin was very hot and dry, and there was very 
great drowsiness and inattention. In other cases the pulse was 140, 128, 
and 124. The acceleration of the pulse usually lasts three or four days, 
after which it falls, so that by the end of a week it is seldom over 70, 
80, or 90. The heat of skin is not very great in most instances, and 
generally subsides rapidly and disappears after a few days. In acute 
secondary attacks, the febrile symptoms are more marked as a general 



204 PLEURISY. 

rule, than as has just been described, because of the existence of the con- 
current disease. 

The countenance presents no particular characters, except that an ex- 
pression of pain passes across it occasionally when the child coughs, or 
takes a deep breath. It is seldom deeply flushed as in pneumonia. The 
alae nasi are dilated only during the continuance of the difficulty of respi- 
ration. 

The decubitus is generally dorsal or indifferent. In two cases observed 
by myself, in which the effusion was large, the number of inspirations was 
always from three to five greater when the child laid on the sound, than 
when on the affected side. 

Headache is often present during the first few days, in children over six 
years of age, and is sometimes very severe. 

Convulsions are said to occur sometimes at the onset in very young 
children. The strength is not usually much diminished, except during 
the acute period. The appetite is diminished and the thirst acute, but 
neither of these symptoms is so marked as in pneumonia. The tongue is 
usually moist, and sometimes covered with a coat of whitish fur; the ab- 
domen is natural. 

Bilious vomiting is said to occur in more than half the cases. The 
stools are generally regular, or there is some constipation. 

Auscultation practised soon after the invasion generally reveals rude or 
bronchial respiration without any rhonchus. The percussion is dull. The 
cough, pain, fever, and difficulty of breathing continue for several days, 
after which all but the cough generally disappear, while that commonly 
persists in a mild form. In acute cases, the appetite now begins to return, 
the thirst moderates, and auscultation reveals only feebleness of the 
respiratory murmur and slight dulness on percussion. The general 
symptoms cease soon after this, and the patient is entirely convalescent in 
from one to three weeks, though feeble respiration and diminished sono- 
reity sometimes persist for a longer period. 

Chronic 'pleurisy may follow the acute form, or occur as an idiopathic 
disease. In the former case, the acute symptoms diminish after a variable 
length of time, but the fever does not cease entirely and often recurs 
towards evening. In the latter case there is very slight fever or none at 
all, and the pain is vague, uncertain, and attracts but little notice. In 
one case that I attended the cough was frequent, rather dry, and very 
painfuj for the first few days, after which it became looser and ceased en- 
tirely, though the inferior two-thirds of the right side were filled with 
effusion for a period of two weeks afterwards. In a second, in which the 
whole of the left side was occupied by the effusion, there was no cough 
whatever; neither the mother nor myself ever perceived any. In a third, 



DIAGNOSIS. 205 

there was a very slight, infrequent cough during the first day, but after 
that, though the effusion occupied the right side up to the spine of the sca- 
pula, there was none through the day, and merely a little hacking at night. 
The respiration is somewhat accelerated in all cases, and when the effusion 
is very large, and especially when it is purulent and attended with violent 
hectic fever, it is sometimes excessively labored and difficult. In the 
cases that I have seen, however, even when the effusion has been very 
large, the breathing has not been difficult. In one case it was between 
40 and 50 during the first two days, after which it fell, as the effusion 
took place, to 30. In a second it was 45 at first ; at the end of a week 
it was 38 ; at the end of the third week, as the effusion was being ab- 
sorbed, it had fallen to 28, soon after which the recovery was completed. 
In a third it was so slightly disturbed that I did not suspect any disease 
of the chest. On the 14th day, the effusion reaching then nearly to the 
spine of the scapula, the breathing varied between 40 and 28 during 
sleep, but during the waking state there was no visible oppression. The 
effusion takes place gradually, and is generally large. The percussion 
is now entirely dull over a greater or less extent of the side, and the re- 
spiratory sound is suppressed. The side is evidently enlarged, the increase 
of size being visible to the eye and ascertainable by measurement. If the 
case continues and terminates unfavorably, the child emaciates, grows 
pale, has night-sweats and hectic fever, and dies at last in a state of pro- 
found exhaustion. In favorable cases, on the contrary, the effusion is 
gradually absorbed, and the patient recovers with a contraction of the side. 
In some rare instances the fluid has been evacuated by an opening through 
the parietes of the thorax, caused by ulceration or made by a surgical 
operation; and in others again by an opening into the lung, through 
which the fluid has been expectorated. The recovery by absorption has 
been known to take place two and five months after the invasion. In one 
case that I saw, the duration from the time when the effusion took place 
to its complete absorption was five weeks ; in a second it was between six 
and seven weeks, and in a third seven. 

Diagnosis. — Pleurisy may be confounded with pneumonia or hydro- 
thorax. From the latter affection it is to be distinguished by the absence 
of pain in that disease, by the existence of the effusion on both sides of the 
thorax in most cases, and by the fact that hydro thorax generally follows 
as a consequence of some previous disease, particularly the eruptive fevers 
or nephritis. 

The distinction between acute pleurisy and lobar pneumonia is more 
difficult than that between pleurisy and hydrothorax, and in some instances 
is subject to considerable doubt. It may generally be arrived at, however, 



206 



PLEURISY. 



by attention to the differences laid down in the following table, which is 
taken from the Bibliotheque du Medecin Praticien. 



ACUTE IDIOPATHIC PLEURISY. 

Frequent after six years of age ; rare 
under that age. 

Begins with dry cough, sharp tho- 
racic pain, bronchial and metallic re- 
spiration during inspiration, either on 
the first day or later, and more rarely 
with obscurity of the respiratory sound. 

Modification of the physical signs by 
change of position. 

Fever and acceleration of the respira- 
tion usually moderate. Rapid diminu- 
tion of these symptoms from the fourth 
to the seventh day. 

Expectoration absent or very slight. 

No rhonchi. 



Absence of vibration of the thoracic 
parietes during speaking or crying. 

Course of the disease irregular ; rapid 
disappearance in some cases, prolonged 
duration in others. The bronchial re- 
spiration is substituted or masked by 
feeble respiration. 



ACUTE IDIOPATHIC PNEUMONIA. 

Frequent after six years of age ; 
more rare under that age, but much 
less so than pleurisy. 

Begins with cough, slight thoracic 
pain, and crepitant or subcrepitant 
rhonchus ; at a later period there is 
bronchial respiration during the expi- 
ration and bronchophony. 

No modification under like circum- 
stances. 

Fever violent; considerable accele- 
ration of the respiration. Diminution 
of these symptoms less marked, less 
rapid, and not before the sixth or ninth 
day. 

Expectoration mucous, sometimes 
sanguineous, very rarely rust-colored. 

Rhonchi preceding, following, and 
often accompanying the bronchial re- 
spiration. 

Augmentation of vocal resonance very 
sensible in older children, and in a less 
degree in all. 

Course of the disease regular; stea- 
dily increasing, in most cases, and then 
diminishing from the sixth or ninth 
day. Bronchial respiration more dis- 
seminated. 



The chronic form of pleurisy with extensive effusion, may be easily dis- 
tinguished by the history of the case, by inspection, palpation and mensu- 
ration of the chest, by the nearly total absence of sonoreity and of the re- 
spiratory murmur except at the inner edge of the scapula, and by atten- 
tion to the character of the general symptoms. 

Prognosis. — Acute pleurisy is rarely a fatal disease in healthy sub- 
jects. When it occurs as a complication of some other malady, on the 
contrary, it is much more apt to terminate unfavorably. The degree of 
fatality in secondary cases will depend, of course, in great measure, on that 
of the primary disease. Pleuro-pneumonia is a more dangerous disorder 
than either alone. Of 5 cases of primary pleuro-pneumonia, observed 
by Rilliet and Barthez, 2 died j while of 10 secondary cases, 8 died. 

Chronic pleurisy is generally a serious, and not unfrequently, a fatal 



TREATMENT. 207 

disease. Of 5 cases, observed by the authors just quoted, 2 proved 
fatal. 

Of the 16 cases that I have seen, 2 died. These were both primary 
cases, but both occurred in infants, one at 6 weeks, and the other at 13 
months. Of the 14 children that recovered, the youngest was between 3 
and 4 years of age, while six were between 4 and 5 years of age, and the 
remainder over that age. In my experience, therefore, the two youngest 
were those which died, as might have been expected. 

Treatment. — The hygienic treatment in this, as indeed in all the 
diseases of children, is of the utmost importance, and ought to be regu- 
lated by the practitioner himself. In all forms of the disease, the child 
should be carefully protected from cold, and in the acute form, kept at 
rest, and if possible, in bed. The diet must be very strict, and should 
consist for a few days of nothing but the weakest preparations of milk. 
After the fever has disappeared, bread and milk, vegetable soup with a 
few oysters boiled in it to make it agreeable, and gradually rice, potatoes, 
and at last small quantities of meat, may be allowed. In the chronic form 
the diet ought to be less strict, but regulated with equal care, as to quan- 
tity and material. In that form the patient should be taken into the air 
if the weather be mild and dry, and in winter the chamber ought to be 
well aired from time to time. 

Bloodletting. — Depletion ought to be employed in acute pleurisy, as a 
general rule. Blood may be drawn either by venesection, cups, or leeches, 
the quantity to be regulated by the age and constitution of the patient. 
Venesection is preferable to local depletion, unless there be some contra- 
indicating circumstance. From four to six ounces may be taken generally 
from a child between four and six years of age. It is seldom necessary to 
repeat the operation ; when, however, the acute symptoms are not at all 
relieved by the first detraction, it would be proper and useful to resort 
again to a small venesection, to leeching, or to take two or three ounces 
of blood by cups, as recommended in the article on pneumonia. 

Depletion ought to be avoided in most of the secondary cases unless 
the symptoms are very acute and the child strong and vigorous ; also in 
all chronic cases, after the febrile symptoms have been dissipated, and in 
feeble, delicate children, or, if resorted to in these, it should be used with 
very great circumspection. 

Antimonials. — A moderate use of the antimonials is of great service in 
the acute stage of the disease. Small doses of antimonial wine and sweet 
spirits of nitre, or fractional doses of tartar emetic, as recommended in 
the article on pneumonia, will generally cause the fever, dyspnoea, and 
cough to subside rapidly. Large doses seem to be unnecessary in any 
case, and are liable to be inj urious in many. 



208 PLEURISY. 

Alteratives. — Many writers recommend the habitual employment of 
the mercurial preparations in connexion with bloodletting. It seems to 
me, however, that they are, to say the least, seldom necessary in acute 
cases, since the majority of these are nearly certain to recover without a 
resort to them; and it is better, as has already been said, to avoid the 
use of mercury in children when there are other and less powerful reme- 
dies which may be resorted to instead. When, however, acute pleurisy 
tends to assume the chronic form, and in confirmed chronic cases also, 
they would seem to be more clearly indicated, though under such circum- 
stances, I have succeeded in curing three cases, as I shall presently show, 
without a resort to them. Nevertheless, calomel combined with, digitalis, 
has been recommended by very high authority under these circumstances. 
From a quarter to half a grain of that preparation, with a quarter of a 
grain of powdered digitalis, may be given every two or three hours. 

The remedy employed by myself, after the disappearance of the acute 
symptoms, and when the effusion had taken place, was in two cases, iodide 
of potassium in syrup of sarsaparilla, according to the following formula : 

R — Potass. Iodidi, grs. xvi. 

Syrup. Sarsap. Comp., 

Aquae, aa^i. — M. 

Dose — A teaspoonful three times a day. 

In a third case the remedy employed was the syrup of the iodide of iron, 
of which from thirty to forty drops should be substituted for the iodide of 
potassium in such a mixture as the above. Under this treatment, combined 
in two cases with the application of a Burgundy pitch plaster to the side, 
the effusion disappeared in from two to four weeks, though diuretics had 
failed to make any impression on the cases. 

Diuretics are highly recommended in the treatment of cases in which 
effusion has taken place. Those chiefly employed are squills, digitalis, 
and nitre. The squill is given alone, or in combination with calomel or 
digitalis, or with both. The dose of the powder of squill or digitalis is 
about a quarter of a grain every two or three hours. The squill may be 
used also in the form of syrup or oxymel, and the digitalis in tincture. 
These two substances may be employed in the following formula : 

R — Acet. Scillae, gii. 

Tinct. Digitalis, gtt. xxx. 

Aquse Fluvial., ^iv. — M. 

Of this a teaspoonful is to be given three or four times a day to children 
two years old. This formula was made use of for several days in two of 



TREATMENT. 209 

the three cases already referred to, without any perceptible diminution of 
the amount of the effusion, whereupon it was suspended, and the iodide 
of potassium, as above recommended, substituted, and with much better 
effect. 

Purgatives ought to be used during the acute stage of pleurisy to an 
extent sufficient to keep the bowels soluble, and to act as mild evacuants. 
In chronic cases, on the contrary, they are particularly recommended as 
evacuants, in order to deplete the blood-vessels, and thus hasten the ab- 
sorption of the effusion. So far as my experience goes, this treatment is 
unnecessary, as diuretics and alteratives are generally sufficient, without 
a resort to violent remedies which must irritate the intestinal mucous 
membrane, always extremely susceptible in children, to a dangerous 
degree. 

External remedies. — Blisters are very generally employed in the acute 
form to relieve pain and dyspnoea, and in the chronic to hasten the ab- 
sorption of the effused liquid. I did not apply them in the cases under 
my charge, having succeeded very well without ; but would not hesitate 
to make use of a small one applied for a not longer period than two 
hours, if the pain and oppression continued after sufficient depletion and 
the use of antimonials. In chronic pleurisy, the application of a large 
Burgundy pitch plaster, made rather weaker than what is used for adults, 
and large enough to cover nearly the whole side, would be preferable to 
blisters. 

Tonics are often necessary in chronic, and sometimes after the febrile 
symptoms have subsided, in acute cases occurring in feeble and delicate 
children. The most suitable are quinine, in the dose of a grain morning 
and evening, small quantities of very fine port wine, and the preparations 
of iron. 

Paracentesis. — When, in chronic pleurisy, the effusion is very large ; 
when there is no disposition to absorption, notwithstanding the use of 
proper remedies; when the child is becoming very debilitated, and is 
attacked with hectic fever and night-sweats ; the operation of paracentesis 
has been recommended by very high authority, and has been performed 
with entire success on several occasions. M. Heyfelder (Arch, de Med., 
3eme serie, t. v. p. 59), performed it in one case eight weeks, and in an- 
other four months and a half, after the beginning of the attack. Both 
cases recovered; the lung expanded again, the opening closed, and the 
respiration was nearly alike over both sides. 

Case of chronic pleurisy of the left side, beginning with acute symptoms ; 
extensive effusion with displacement of the heart to the right of the sternum ; 
recovery. — February 12th, 1846. — The subject of the case is a boy four 
years old, of delicate stature and appearance, but enjoying good health. 

14 



210 PLEURISY. 



adly 



I saw him first at 1 p.m. He was perfectly well yesterday, slept soundly 
last night, and rose apparently in good health this morning. He ate his 
usual breakfast, but complained afterwards of feeling unwell. Soon after 
this he complained of headache, of soreness and weakness of the knees in 
going up stairs, and then of violent pain in the left side beneath the arm- 
pit. 

At the time of my visit he was in bed, in the following condition : 
Pulse 130, full and strong; skin warm and moist; headache; sharp, 
severe pain at the praecordia, extending backwards under the armpit, and 
aggravated by motion, crying, and by deep inspirations ; respiration quick 
and jerking. No cough at all, absolutely none. Abdomen natural ; 
neither vomiting nor diarrhoea. Tongue slightly furred, moist. Action 
of heart violent; impulse strong, and felt over a large space; sounds 
loud and strong ; to the left and beneath the nipple, a soft murmur in 
second sound. Percussion dull over a larger space than natural. 

Behind, percussion dull over whole of left side ; natural on right side. 
Respiration natural on the right side; feeble and indistinct, without 
bronchial sound on the left. 

Ordered a teaspoonful each of extract of senna and syrup of rhubarb, 
to be given immediately. To have a warm bath in the evening, and to 
take one of the following powders every two or three hours, beginning in 
the evening. 

R. — Pulv. Opii et Ipecac, grs. iij. 

Potass. Nitrat., grs. vi. 

In pulv. no. vi. 

February 13. — Passed a restless night. Better to-day. Pulse 130, 
softer; skin moist. Impulse of heart less violent. Pain not so severe. 
Respiration still quick, and when the child is excited or irritated, it 
becomes jerking, while at other times it is quiet. Physical signs as 
before, except that the murmur in the second sound of the heart is no 
longer heard. Ordered three ounces of blood to be drawn by leeches 
from the left side ; powders to be continued so as to allay restlessness 
and pain. 

February 14. — Has had a better night. Pulse less frequent. Respi- 
ration 30, and without jerking ; no cough at all ; makes no complaints of 
pain. The appetite is returning. 

February 15. — Better in all respects; no fever nor pain; no cough. 
Physical signs as before. 

The case went on until the 27th of March, when I paid my last visit, 
making the whole duration of the case over six weeks. During the last 
two weeks of February, there were no acute symptoms. The fever had 



CASE. 211 

disappeared entirely. The respiration continued, however, from 28 to 30 
during all that time. The effusion occupied nearly the whole of the left- 
side, which was manifestly larger than the right, and the intercostal spaces 
were protruded. Behind, there was total flatness on percussion from the 
spine of the scapula downwards, and in front from a short distance below 
the clavicle. The respiratory murmur was absent in the lower three- 
fourths of the dorsal region, and feeble above. In front, respiration was 
heard only above and just beneath the clavicle. In the course of 
this period, the heart was gradually forced over to the right side of the 
sternum, so that at last its impulse was felt, not to the left, but to the 
right of the sternum. The cardiac sounds were loudest and most distinct 
in the same region. The displacement was so remarkable that the mother 
discovered it herself, I having avoided telling her, to save her from 
anxiety. The new position of the heart did not seem to produce any 
inconvenience, in addition to that occasioned by the pleuritic effusion. 
During the last two weeks of March, the child was kept in bed ; his diet 
was milk and bread ; a large Burgundy pitch plaster was kept on the 
side, and he took internally vinegar of squills, and tincture of digitalis. 

Finding that the effusion remained stationary under this treatment, I 
prescribed a grain of iodide of potassium to be given three times a day, in a 
teaspoonful of compound syrup of sarsaparilla. The diet was changed at 
the same time. He was allowed small quantities of meat every day, and 
was taken from bed and placed in a chair by the window. Under this 
treatment, he gradually improved, so that by the 27th of March, when I 
paid my last visit, the effusion had in great measure disappeared, and he 
was able to play about the room all day. The side was slightly con- 
tracted; the respiration was pure and vesicular, but rather more feeble 
than on the left side; the heart had returned to its natural position. 

I examined this child in the course of the year 1852, and found him 
to be in excellent health. Excepting a slight contraction of the left side, 
there was no perceptible difference between that side and the right. 



ARTICLE V. 



HOOPING-COUGH, OR PERTUSSIS. 



Definition; Synonymes; Frequency. — Hooping-cough is charac- 
terized by a hard, convulsive cough, occurring during expiration, and 
accompanied by long, shrill, and laborious inspirations, which are called 



212 HOOPING-COUGH. 

hoops. The cough occurs in paroxysms, which are terminated by the 
expectoration of tough phlegm and often by vomiting. 

The disease is known by various other names, of which the most common 
are tussis ferina, chincough, and kincough. The frequency of the disease 
is exceedingly variable, as it occurs both in the sporadic form and as a 
widely prevailing epidemic. Some idea of its frequency may be gained 
from the facts that during the five years, from 1844 to 1848, inclusive, 
there were 390 deaths from it in Philadelphia, under fifteen years of age. 
During the same time there were 772 deaths from pneumonia; 756 from 
croup ; and 613 from bronchitis. 

Causes. — Age. — It occurs generally in young children. Of 135 cases 
of the disease that I have seen in children in my own private practice, 21 
occurred in the first year of life, 97 between the ages of 1 and 7 years, and 
17 between 7 and 12 years. To be more explicit, I will state that of 120 
cases in which the age was accurately noted, 6 occurred in the first six 
months of life, 9 between 6 and 12 months, 18 in the second year, 9 in the 
third, 19 in the fourth, 10 in the fifth, 20 in the sixth, 7 in the seventh, 9 
in the eighth, 5 in the ninth, and one each in the tenth, eleventh, and 
twelfth years of life. Of 130 cases in children, collected by M. Blache, 
106 were between 1 and 7 years of age, and only 24 between 8 and 14. 
Of 29 cases observed by MM. Rilliet and Barthez, there were 26 between 1 
and 7 years, and 3 between 8 and 12. It is stated by MM. Blache, Billiet 
and Barthez, and Valleix, to be most common in girls. Of 135 cases 
observed by myself, 65 occurred in boys, and 70 in girls. Some writers 
have asserted that certain constitutions and hereditary influence predispose 
to the disease. So far as my own experience goes, it has seemed to attack 
indifferently those who were simultaneously exposed to it. The fact of 
its being propagated by direct contagion is proved beyond doubt by 
numerous observations. I have rarely known one child in a family to be 
attacked without its extending to all the others not protected by having 
had the disease previously. That it often appears also in the form of an 
epidemic, is established by the testimony of many writers, so that at pre- 
sent no doubt is entertained upon this point. 

Symptoms.— It is customary to describe three stages of hooping-cough. 
The first is called the stage of invasion, or the catarrhal stage ; the second 
the stage of increase, or the spasmodic stage ; and the third the stage of 
decline, which is characterized by an amendment of all the symptoms. 

First stage. — The great majority of the cases begin with the ordinary 
symptoms of simple catarrh. These are coryza, sneezing, slight injection 
of the conjunctivae, and dry cough. The cough rarely has any peculiarity 
in the beginning which will enable us to distinguish it from that of an 
ordinary cold, though some persons have asserted that they could recog- 



SYMPTOMS. 213 

nise it. I have often listened with great care to the sound of coughs 
which parents supposed might be hooping-cough, but was always obliged 
to confess my inability to determine, until time gave them more decided 
characters. In addition to the symptoms enumerated, there is generally 
more languor, lassitude, drowsiness, and irritability, than are commonly 
present in simple catarrh. In a small proportion of cases the first stage is 
wanting, and the disease assumes its peculiar features from the first. The 
duration of this stage is very uncertain, and is ascertained with difficulty. 
My own experience would fix it at about two weeks as the average, though 
it may last undoubtedly a much shorter, or longer period. The earliest 
period at which I have known the distinctive hoop of the disease to be 
heard is three days. In another case it was five days. I have also known 
it to appear at a later period than usual. In a good many instances it has 
been as late as three weeks, but very rarely later. 

Second stage. — At the beginning of this stage the disease has assumed 
its peculiar convulsive and paroxysmal character. It consists of violent 
fits or paroxysms, or, as they are often called, kinks of cough, recurring 
after longer or shorter intervals. Just before the paroxysm the child 
seems restless, anxious, and irritable, or else keeps perfectly quiet and 
evidently tries to retard its approach. When it begins, the child, if lying 
down, rises up suddenly, or if playing about runs to take hold of some 
fixed object, by which to support itself during the accession. The cough 
is dry, spasmodic, and sonorous, and occurs in a succession of short, rapid 
expirations, by which the thorax seems to be emptied of all its air, with 
violent efforts. It is followed by one or two long and deep inspirations, 
which are accompanied by the peculiar hoop to which the disease owes its 
name, and which are caused by the drawing of the air rapidly and forcibly 
through the narrowed glottis, which is spasmodically closed. During the 
fit the face becomes deeply suffused or even purple, and swollen ; the eyes 
are watery, and the countenance is expressive of great anxiety, and after 
the fit is over, of fatigue and exhaustion. The latter symptoms are, as M. 
Valleix remarks, the signs of partial asphyxia, and are the result doubt- 
less of the complete expulsion of air from the thorax, and a consequent 
momentary suspension of the function of hasmatosis. There is almost 
always an expectoration of colorless ropy fluid, often accompanied by 
vomiting, at the close of the fit of coughing, and the patients usually 
appear weak and languid for a short time, after which they return to 
their play. 

In very severe cases there are other symptoms in addition to those just 
mentioned. Hemorrhages from the mouth, ears, nose, lungs, and beneath 
the conjunctivae, are not unusual. I have myself seen several instances of 
epistaxis, one of effusion into the eyelids, and one of extensive sub-con- 



214 HOOPING-COUGH. 

junctival ecchymosis, and I am well acquainted with the history of another 
case, in which there was bleeding both from the nose and ears. In 
one case, in a girl between five and six years old, that occurred to myself, 
in which the paroxysms were violent, the spells were accompanied in the 
latter half of the fourth and in the fifth week, by a discharge of a good 
deal of blood from the mouth. This took place particularly during the 
night-spells, so that in the morning the basin would contain several tea- 
spoonfuls of blood. It was not from the nose. It was bright in color, 
pure, except that it was intermingled with sero-mucous expectoration, 
but it was not intimately blended with the sputa, nor was it streaked 
through the mucus as it sometimes is in the pneumonia of children. On 
one occasion it was seen to fly from the mouth in a little spirt, as though 
from a vessel. The child was lively and well all this time, playing about, 
eating well, strong, not thirsty, without pain, not oppressed between the 
spells, and sleeping naturally between the paroxysms at night. The only 
altered physical sign was slight dulness on percussion over the upper part 
of the right lung behind, with some subcrepitant rale at that point, but 
without bronchial respiration. After lasting twelve days, it ceased ; the 
child got well gradually, and continues strong and hearty to the present 
time (November, 1852). The attack occurred in January and February 
of 1849. In another, in a girl two years of age, which came under my 
own observation, a species of syncope, a state of insensibility without con- 
vulsive movements, accompanied by great paleness, occurred after many of 
the paroxysms. 

I have met with general convulsions in ten cases, three of which proved 
fatal. In two other cases, both occurring in infants under six months, the 
paroxysms of cough were accompanied by the most violent struggling and 
oppression, and by deep blueness of the hands and feet, like that of severe 
cyanosis. 

In some instances, after the paroxysm is apparently over, the child will 
begin within a few instants to cough again, and may in this way have 
several fits in such rapid succession as to make an almost continuous 
paroxysm. It is quite common for this to happen twice, and in one case 
which I saw, it occurred three times on several occasions. The ordinary 
duration of a paroxysm or kink, is from a quarter to three-quarters of a 
minute, though it may last as long as two minutes, or according to some 
even longer. In a case that occurred to myself, one paroxysm lasted the 
extraordinary period of fifty-five minutes. That it was really a paroxysm 
of the disease, I am quite sure, as it chanced that I reached the house 
shortly after it began, and witnessed the greater part of it myself. The 
number of accessions in twenty- four hours is very irregular. It depends 
chiefly on the stage and violence of the attack. During the height of the 



SYxMPTOMS. 215 

disease, I have generally found them to number about 40. In some rare 
cases, however, they are much more numerous, and amount to 70 or 80. 
They are generally most frequent in the course of the third or fourth week, 
after which they remain stationary as to frequency for two or three weeks, 
and then decline gradually. The paroxysms may occur spontaneously, 
the child being often disturbed from sleep by their sudden occurrence, or 
they may be excited by various circumstances, such for instance as contra- 
rieties, a fit of crying, change of position, eating, violent exercise, and 
imitation. I have frequently seen an attack brought on by the sight of 
another child in a paroxysm of the disease. The duration of the second 
stage may be stated to be about 30 or 40 days in most cases. 

Third stage. — It is impossible to fix a precise limit from which to date 
the beginning of this stage. It is generally, however, said to commence 
from the time when the disease is evidently on the decline. The pa- 
roxysms now grow less frequent and less violent, the cough reassumes 
some of the catarrhal features which it had at first, and gradually loses 
its peculiar spasmodic character. The child's general health improves, 
the appetite becomes vigorous, the strength is invigorated, the sleep again 
becomes sound and tranquil, and the disease disappears. The duration of 
this stage, is uncertain like that of the two others. MM. Rilliet and Barthez 
state it to be short in uncomplicated cases (ten to fifteen days), and are 
of opinion that when it has been supposed to have lasted several weeks or 
months, it has been the result of some complication, as chronic dilatation 
of the bronchia, tubercular disease, etc. It happens not unfrequently, 
however, that after the disease has apparently ceased, all the distinctive 
characters of the cough recur, if the child chance to take cold within a 
few weeks or even longer after its disappearance. 

In cases of pertussis unaccompanied by complications of any kind, 
there are no marked general symptoms. There is seldom any fever, the 
appetite continues good, and with the exception of occasional languor and 
fatigue, and irritability of temper, the child appears to be well. 

The total duration of the disease, in simple cases, may be set down at 
from one to three months. I have never known a case to last so short a 
time as a month, and have rarely found the whole duration much within 
three months. 

Complications. — Though it has happened tojne on several occasions, 
to meet with children who have been very ill from the violence of the 
disease under consideration, in its uncomplicated condition, I have never 
known a case to prove fatal, except in consequence of some kind of com- 
plication. It is exceedingly important, therefore, that the various acci- 
dents, apt to occur in the course of the disease, should be carefully con- 
sidered. 



216 HOOPING-COUGH. 

Convulsions. — This complication is not a rare one, since it occurred in 
5 of 29 cases observed by MM. Rilliet and Barthez, and in 10 of 135 ob- 
served by myself. It is one of the most dangerous accidents liable to occur 
in the course of the disease. Of the 7 cases reported by the authors 
quoted (5 of their own, and 2 belonging to M. Papavoine), 6 died. Of my 
10 cases, 3 died. In all that I have seen, the convulsions were general, 
extremely violent, and accompanied by insensibility in the fatal cases to 
the last, and in the favorable ones, for several hours. In two of the fatal 
cases the pertussis had lasted nearly two months, and was accompanied 
by extensive bronchitis. The fatal event took place within twenty-four 
hours from the supervention of the spasms. The subjects were eight and 
nine months of age respectively. In the third case, the convulsions came 
on in the seventh week of the disease, in a child who had been laboring 
for a number of days under bronchitis. They ended fatally in seven 
hours. 

One of the favorable cases occurred in a child five months old, who had 
been attacked with bronchitis three days before the occurrence of the con- 
vulsions, which came on during the height of a severe paroxysm of 
coughing. The convulsive movements were general, and continued for 
about half an hour, after which the child was drowsy or irritable for some 
hours longer. The hooping-cough continued to be severe for two weeks 
after this, as many as 42, 46, and 48 paroxysms occurring every day. 
At last, however, perfect recovery took place. The second favorable case 
was that of a girl between two and three years old, in whom a convulsion 
occurred in the third week of the disease, before the paroxysms had 
become violent, and evidently in consequence of an attack of fever 
dependent upon dentition. The seizure lasted only a few minutes, was 
followed by drowsiness for a few hours, but on the following day all the 
unpleasant symptoms had disappeared. In a third case, in a boy between 
two and three years old, a violent convulsion occurred at the end of the 
second week, at the beginning of an attack of pneumonia. The child 
remained very ill, and nine days afterwards had another convulsion, which 
was much slighter than the first. After this he gradually recovered. In 
a fourth case, in a girl between two and three years old, a slight but 
well-marked convulsion occurred at the onset of an attack of bronchitis, 
which took place at the beginning of the third week of the hooping-cough. 
The bronchitis proved to be very severe, but there was no return of the 
spasm, and the child recovered. In a fifth case, in a boy nine months old, 
a severe fit occurred in the sixth week, just after the child had been brought 
home from an expedition to procure his daguerreotype. It lasted fifteen 
minutes, and was attended with total insensibility, and purple discoloration 



COMPLICATIONS. 217 

of the face, but in half an hour after, the patient was nursing well, and was 
entirely conscious. There was no return of the convulsions, though the 
disease was very severe after this attack. In the sixth case, which oc- 
curred, like the last, in a boy nine months old, a slight convulsion occurred 
during one of the paroxysms in the fifth week, but was not followed by 
any bad consequences. 

Bronchitis is a very frequent complication. The authors above quoted 
found it to exist either alone, or combined with pneumonia, in half of the 
fatal cases. Of the 135 cases observed by myself, it existed to a greater 
or less extent in 31. In 24 of these it was mild or only moderately 
severe, and all of these recovered. In 7 it was severe and very extensive, 
or else capillary, and of these 3 died. In fatal cases it has often been 
found accompanied by continuous dilatation of the smaller bronchia. 

Pneumonia, according to the authors above quoted, is about as frequent 
as bronchitis. When, however, the fatal termination took place soon 
after the beginning of the disease (18th, 26th, or 27th days), it was not 
generally present. After these periods, on the contrary, it was almost 
always observed. As these authors, however, include, under the title of 
lobular pneumonia, many cases of bronchitis with collapse, it is clear that 
a large number of their cases of supposed pneumonia, ought to have been 
ranged under the head of bronchitis. For my own part, I have met with 
only four well-marked cases of pneumonia. Two of these occurred in 
girls of seven and nine years old respectively, one in a girl between one 
and two years of age, and the fourth in a boy between two and three years 
old. They all recovered. The degree of danger from this complication 
is in proportion to the earliness of the age at which the disease occurs, 
and to the extent of the inflammation. 

Emphysema has been supposed by some to be a common result or 
accompaniment of the disease. This is denied, however, by others. I 
have never' observed it myself, and as nearly all the children whom I have 
attended with pertussis continue under my charge, I should certainly 
have noticed it, were it of common occurrence. 

Vomiting is a very frequent incident in pertussis, but ought not to be 
regarded as a complication unless dependent on some disease of the 
digestive organs, or symptomatic of cerebral disease. Where it occurs in 
simple cases, or in those complicated with bronchitis or pneumonia, it has 
always seemed to me to be advantageous. 

Tuberculization is not infrequent, according to the French authorities, 
as a sequence of the disease. In the majority of the cases the tubercular 
deposit is concentrated in the lungs and bronchial ganglions. I am dis- 
posed to believe that it is of rare occurrence in this city, at least amongst 



218 HOOPING-COUGH. 

the better classes, as I very seldom meet with it, or indeed with any form 
of tubercular disease in children. 

Diagnosis ; Prognosis. — The diagnosis of pertussis is difficult only 
during the first stage of the complaint. It seems to me, indeed, impos- 
sible to distinguish during that stage, between it and simple mild laryn- 
gitis, or the mild catarrhal attacks which are so common in our climate. 
After it has once fairly entered upon the second stage, it is scarcely pos- 
sible to confound it with any other malady. MM. Billiet and Barthez state, 
however, that acute bronchitis with paroxysmal cough is not unfrequently 
mistaken for pertussis. The mistake will scarcely be made, if it be recol- 
lected that in acute bronchitis with paroxysmal cough, the invasion is 
sudden ; that there is violent fever, great dyspnoea, and the physical signs 
of bronchitis ; that the hoop is generally wanting, or feebly marked, and 
that the disease is violent and rapid in its course ; all of which circum- 
stances are widely different from what occurs in pertussis. 

The same authors assert that tuberculosis of the bronchial ganglions 
gives rise to a cough which may be mistaken for pertussis. The follow- 
ing table extracted from their work will show the differences between 
the two disorders. 

PERTUSSIS. TUBERCULOSIS OE THE BRONCHIAL 

GANGLIONS. 

Often epidemic, attacking several Always sporadic; non-contagious, 
children at once ; transmissible by con- 
tagion. 

Three distinct stages, of which only No distinct stages, 
the second accompanied by kinks. 

Kinks attended with hooping, ropy Kinks generally very short, without 
expectoration, and vomiting. hooping, ropy expectoration, or vomit- 

ing. 

Pure respiration in the intervals be- Physical signs of tuberculosis of the 
tween the kinks. ganglions ; but in certain cases, absence 

of these signs. 

In the intervals between the kinks Accessions of asthma in some cases, 
respiration and pulse natural, so long with the kinks ; continuous febrile move- 
as the disease is simple. ment, with evening exacerbations ; 

sweats ; progressive emaciation, &c. 

Voice natural. Voice sometimes hoarse. 

Course generally acute. Chronic course. 

Prognosis. — Pertussis is rarely a dangerous or fatal disease so long as 
it remains simple. Of the 135 cases observed by myself, 88 were simple, 
all of which recovered. Nevertheless, even the simple disease does some- 
times terminate fatally, from the excessive violence of the paroxysms 
of coughing. 



PROGNOSIS — NATURE. 219 

The danger in hooping-cough, which is considerable, depends, there- 
fore, almost entirely on the complications which are so apt to occur, for 
which reason the physician should watch with the closest attention in 
order to prevent their occurrence, and that he may recognise and treat 
them in their earliest stages. The most dangerous complication is con- 
vulsions, and after that bronchitis and pneumonia. So long as the child 
seems well and lively, and without fever or dyspnoea, in the intervals 
between the fits, there is nothing to be feared. But if, on the contrary, 
it becomes languid and irritable, with indisposition to take food, feverish- 
ness, and some increase of the rate of respiration, the practitioner should 
be upon his guard. A very early age and natural delicacy of constiution 
are unfavorable circumstances in the disease. Some form of complication 
occurred in 47 of the 135 cases observed by myself. Of the 47, 6 died. 
Three of the 6 died in convulsions, which came on and were no doubt 
caused by severe bronchitis. Two of these cases occurred in children of 
8 and 9 months old respectively, and they proved fatal in 24 hours after 
the setting in of the convulsions. The third occurred in a boy between 
3 and 4 years old, and caused death in 7 hours. 

The other three fatal cases depended also on bronchitis, but were unac- 
companied by any convulsions whatever. Two of these occurred between 1 
and 2 years of age ; one proved fatal from severe and extensive bronchitis, 
while in the other death took place after several weeks, and from gradual 
wearing out of the powers of life. The third case was that of a child 
between five and six months old, whose death was evidently caused by 
sudden and extensive bronchitis. 

Nature of the Disease. — There is no essential anatomical lesion in 
pertussis, except, perhaps, slight inflammation of the bronchial mucous 
membrane. In most of the cases, the membrane lining the larger and 
smaller air-tubes, and very rarely that of the trachea, is reddened and 
perceptibly thicker than natural, and the tubes contain a considerable 
quantity of frothy mucus, or a thick, viscid, and tenacious phlegm. 

As to the nature of the disease, it seems to me very clear that it ought 
to be regarded as comprising two elements of morbid action, one of which 
consists in slight inflammation of the respiratory mucous membrane, and 
the other of disordered action of the respiratory system of excito-motory 
nerves. It is neither a pure neurosis nor a pure inflammation, but 
partakes of the characters of both, and much more of the former than of 
the latter. The authors of the Compendium de Medecine Pratique (t. ii., 
p. 526) "regard it as a neurosis on the following grounds: 1. "In the 
greater number of cases, the respiratory apparatus presents no kind of 
alteration, or else the lesions are so multiplied or variable that they are 
surely not the real origin of the disease; 2. The clearly remittent course 



220 HOOPING-COUGH. 

of the symptoms and the total absence of fever, unless some complication 
is present, are not observed in ordinary or even specific inflammations j 
3. The cessation or sudden return of the paroxysms under the influence 
of moral emotions or change of place, belong to a disorder of innervation 
and not to inflammation, which commonly passes through certain stages 
before it is resolved ; 4. The complete return to health, the integrity of 
all the functions in slight cases, the resistance which it opposes to treat- 
ment, the uselessness of antiphlogistics, and the success obtained from 
narcotics and antispasmodics, are all so many circumstances peculiar to 
hooping-cough and to many of the neuroses." 

Treatment of Simple Pertussis. — Bloodletting. — Depletion is very 
rarely necessary in simple pertussis. The only cases in which it can be 
called for are those occurring in sanguine children, where the parox- 
ysms are so violent as to endanger the brain by over-distension of the 
vessels. In these cases a small bleeding, or the application of a few 
leeches to the temples or behind the ears, may be proper ; but even these 
may often be safely treated by reduced diet and by a few doses of saline 
cathartics, without a resort to the more powerful and more permanently 
exhausting means of depletion. As for the treatment of simple pertussis 
by repeated venesections, in the hope of curtailing its duration, or under 
the idea of their being rendered necessary by the violence of the malady, 
it seems to me forbidden by the present state of medical knowledge, which 
informs us that the greater number of the cases do not endanger life so 
long as they remain simple, however violent they appear to be. Of the 
88 simple cases treated by myself, depletion was not used in any, and all 
recovered. 

Antispasmodics. — Of the different remedies of this class which have 
been used in the disease, I shall only mention assafoetida, which is recom- 
mended upon very high authority, and is doubtless useful in moderating 
the severity of the paroxysms. It is much employed in this city as a 
domestic remedy. I have used it myself on several occasions with 
decided benefit, but, as I have obtained better and more constant success 
from other means, I do not very often resort to it. Dewees speaks of it 
as " occasionally useful, but never decidedly efficacious" in his hands. 
Kopp recommends it very strongly, in the dose of six grains three times 
a day in pills, for a child four years old. This seems to me a large dose. 
I have generally given two or three grains three or four times a day to a 
child of that age. 

Narcotics. — Of the various narcotics which have been more or less ex- 
tensively employed, the most important are belladonna, opium, and hydro- 
cyanic acid. Belladonna is highly recommended by several German authors, 
by MM. Rilliet and Barthez, who state that it is beyond contradiction 



TREATMENT. 221 

the one most deserving of confidence, by MM. Trousseau and Pidoux, and 
by Dr. Eberle. It ought to be given with great care, and not continued 
for too long a time. Eberle says that it ought not to be exhibited where 
there is fever and bronchial inflammation. Trousseau and Pidoux employ 
the following formula: R. — Pulv. Belladonnas, gr. iv; Extract. Opii 
Aquos., gr. iv; Extract. Valerianae, 3ss. Ft. in pilul. no. xvi. Grive from 
one to four in the course of the day. If the child dislike the pilular 
form, they give it in syrup, according to the following formula : R. — 
Extract. Belladonnas, gr. iv: Syrup. Opii, Syrup. Flor. Aurantii, aa 3j. 
Misce. Of this, from one to eight teaspoonfuls are to be given in twenty- 
four hours. 

Dr. Sam. Jackson, of Northumberland (Am. Journ. Med. JSc, August, 
1834), recommends this remedy in the very highest terms, and regards it 
as exerting a most powerful controlling influence over the disease. Dr. 
H. Corson, of Montgomery County, Pa. (Loc. cit., Oct. 1852), also 
gives very strong testimony in favor of its efficacy in the disease. Dr. 
Corson says : " During the last seventeen years, I have given the extract 
of belladonna to hundreds of patients, from two months to fifty years of 
age, and am firmly convinced that it has a greater control over hooping- 
cough than any other remedy in common use, and that, while in a few 
cases the system did not seem susceptible to its action, in the doses I 
have prescribed, yet, in nearly all, the disease yielded quickly." He 
asserts that he has cured the disease, effectually and permanently, in 
numerous instances, in from five days to a week, and generally within 
two weeks, with this remedy, while in others it failed entirely. In chil- 
dren under one year old, he begins with one-sixteenth or one-eighth of 
a grain as the dose, to be repeated every two hours, and to be increased 
a little every day, until the proper dose is reached. The doses are 
repeated, and if necessary increased, until the pupils are dilated, the 
face flushed, the mouth dry, and the vision confused. His mode of 
prescribing it is to dissolve eight grains of the extract in one ounce of 
water. Nine drops of this contain just one-eighth of a grain of the 
remedy. For my own part I have seldom used the belladonna, and when 
I have, have failed to obtain from it the admirable effects described by 
Dr. Corson. It is proper to state, however, that .1 only once gave it to 
such an extent as to produce the dilated pupil, flushed face, and dry 
mouth, above referred to. In that one case it did no good whatever. 

Opium is confessedly a very valuable remedy in the disease, not as a 
curative, but as a sedative and palliative. When the cough is frequent 
and fatiguing, especially if the patient have an irritable and nervous 
constitution, some opiate preparation is of the utmost service in modera- 
ting the frequency and violence of the paroxysms, and in allaying irrita- 



222 HOOPING-COUGH. 

bility and restlessness. It is best given in the evening, and in combina- 
tion with ipecacuanha, or with very minute doses of antimony. 

Hydrocyanic acid has been employed by various observers, and is 
highly spoken of by some. Its poisonous properties, however, have 
deterred many, and amongst them, myself, from resorting to it. Inas- 
much as there are other and safer means for conducting the disease to a 
favorable termination, it seems to me useless to venture upon so potent 
a preparation as this. Dr. Atlee, of Lancaster, gave it in the following 
formula: R. — Acid. Hydrocyan., r#j ; Syrup., Simpl., 3j. — M. A tea- 
spoonful to be given morning and evening, and if no uneasiness, dizziness, 
or sickness be produced within forty-eight hours, the dose to be repeated 
three times a day. This prescription is for a child six years old; one 
drop of the acid being added for each year of the child's age beyond one 
year. He has never repeated the dose more than four times a day. 
(Condie's Dis. of Child., 2d ed., p. 337.) 

Emetics and Nauseants are amongst the most important remedies in 
the treatment of hooping-cough, since they exert a powerful influence 
upon the disease, and unless carried to excess, are not in themselves 
likely to be injurious. Some authors recommend the administration of 
an emetic every day or every other day, while others give them according 
to the necessity of the case. Believing that frequently-repeated emetic 
doses are unnecessarily severe, and productive of too much fatigue and 
exhaustion, I have preferred in the simple disease to give only small 
doses of ipecacuanha from time to time, so as to moderate the violence 
of the cough. Tartar emetic is seldom necessary, and ought to be 
avoided if possible, on account of its disposition to irritate and inflame 
the gastro-intestinal mucous membrane. The syrup of ipecacuanha is the 
preparation I have almost always used. From ten to twenty drops, given 
three times a day to a child three years old, will very generally moderate 
the severity of the paroxysms. 

Purgatives are necessary in the simple disease only when constipation 
is present. The mildest ought to be preferred, in order to avoid irritation 
and exhaustion. Castor oil, magnesia, or syrup of rhubarb are the 
best. 

Particular Remedies. — Of the different specific remedies that have 
been employed, none have attained and maintained so high a reputation 
in this city as the carbonate of potassa, which, in the form of the cochi- 
neal mixture, is constantly used both by physicians and as a domestic 
remedy. The following formula is the one generally administered : R. — 
Potass. Carbonat., B j j Cocci, Bss; Sacch. alb., 3j ; Aquse fontis, 3iv. — 
M. Give a dessertspoonful three times a day to a child a year old. 
Believing the carbonate of potash to be the active agent in the mixture, I 



TREATMENT. 223 

have generally left out the cochineal and used the potash alone, dissolving 
it in equal parts of syrup of gum and water. I have frequently employed 
this remedy, and believe that, with the exception of alum, to which I 
shall presently refer, it is the most useful agent in keeping down the 
violence of the disease with which I am acquainted. I have given it in 
the dose of a grain three or four times in the twenty-four hours, to chil- 
dren one and two years old, for several weeks at a time, without witness- 
ing any injurious effects from it. 

Alum is highly recommended as a remedy in pertussis by Dr. G-olding 
Bird (Guy's Hospital Reports, April, 1845). He states that in the 
second or nervous period of the disease, when " all inflammatory symp- 
toms have subsided, and when, with a cool skin and clean tongue, the 
little patient is harassed by a copious secretion from the bronchi, the 
attempt to get rid of which produces the exhausting and characteristic 
cough, alum will be found to be of much value." He adds that he " has 
not yet met with any other remedy which has acted so satisfactorily, or 
afforded such marked and rapid relief." From reading Dr. Bird's remarks 
on alum, and prompted by my knowledge of its admirable qualities in the 
treatment of croup, I was led to make trial of it in the disease under 
consideration, and I believe I may say that it has exerted a more decided 
influence in moderating the violence of the disorder, than any that I have 
ever made use of. I have administered it in 68 cases, beginning in the 
course of the second stage. In all it was beneficial, and in some the 
effects were strikingly useful, the improvement being more rapid than I 
had ever seen to result from other remedies, or to occur when the disease 
has been allowed to pursue its natural course. In a boy between five and 
six years of age, who had been coughing violently for two weeks, the 
paroxysms diminished so much in intensity and frequency after he had 
taken the remedy two days, that he was not once disturbed at night, 
though before he had always been waked several times, and the spells 
which occurred during the day were much less severe. After continuing 
the remedy for ten days, the disease had subsided so much that its 
employment was suspended. Soon after, however, the paroxysms again 
became severe and troublesome. The alum was resumed, and with the 
same results as at first. In another family in which there were three 
children, all of whom had been taking syrup of ipecacuanha, and car- 
bonate of potash for some days, without any good effects, the alum was 
given, and acted as in the case first referred to. The nights were com- 
paratively quiet, and the spells occurring through the day very much 
moderated. I may repeat that, so far as my experience in the above 68 
cases goes, the effects of alum have been more decided and satisfactory 
than those of any other remedy. I have never known it to produce ill 



224 HOOPING-COUGH. 

consequences either at the time of its administration or subsequently, 
though I have given it to children from two months to seven years of age, 
and have continued its use from one to six weeks at a time. If adminis- 
tered in large doses it produces vomiting. It does not constipate, but on 
the contrary, is apt to induce diarrhoea, when continued for some time. 
Dr. Bird gives from two to six grains every four hours. His formula is 
as follows : 

R. — Aluminis, . . . gr. xxv. 

Ext. Conii, * gr. xii. 

Syrup. Rhceados, ^ii. 

Aquge Anethi, ^iii. — M. 

Give a medium-sized spoonful every three hours. 

I have not generally used it in such large doses. To children under one 
year I give from half a grain to a grain, three or four times a day ) and to 
those over that age, two grains every six hours. The formula I have 
employed is the following : 

R. — Aluminis, T)iiss. 

Syrup. Zingib., Syrup. Acacise, Aquse Fontis, aa %i. — M. 

When this is prepared with good syrups, it tastes very much like 
lemonade, and is not at all unpleasant, so that children take it without 
difficulty. The dose is a teaspoonful three times a day, or every six 
hours. 

Sulphur. — Some of the German authorities make frequent use of, and 
greatly commend the effects of flowers of sulphur, both at the beginning 
and throughout the course of the disease. MM. Billiet and Barthez state 
that they saw it succeed several times in the hands of M. Jadelot. I have 
never employed it. It is given in doses of three grains two or three times 
a day, to children from two to four years of age ; and to those who are 
older, in doses of fifteen grains or more in the twenty-four hours. It may 
be administered in powder diffused in milk or syrup, or made into an 
emulsion. It is said not to be purgative in the doses mentioned. 

Various other remedies have been recommended by different authors, 
the most important of which are the subcarbonate of iron used by Dr. 
Steyman, and by Lombard of Geneva; the misletoe (Yiscum Album), 
employed by Baglivi and J. Frank, and recently by MM. Guersent and 
Blache, who give it in powder, in the dose of twelve ,or fourteen grains four 
times a day ; and the cicuta, which is highly spoken of by several Ger- 
man authors. 

Revulsives. — The milder revulsives are useful in certain complications 



TREATMENT. 225 

of pertussis, and as palliatives. To make them the chief basis of the 
treatment, however, which has been done by some, appears to me to be 
wrong. In order to produce a decided impression upon the disease, it 
would be necessary to resort to the more powerful remedies of the class, 
such as rnoxas, issues, tartar emetic ointment, blisters, &c, the use of 
which is not, I believe, warranted by the nature of the disorder. 

Tonics. — In a number of cases that have come under my notice, the 
patient has grown pale and weak in the course of the disease, and this 
without any local complication, but apparently from the disturbance of the 
digestive system that often exists to a greater or less extent, and from the 
exhausting effect of the violent muscular exertion undergone during the 
paroxysms. In such instances, when there has been no fever, or merely a 
little evening febricula, I have often employed tonics with much advantage, 
and never to the injury of the patient. I have generally made use of the 
Huxham's tincture, either alone, in doses of from ten to twenty drops 
three times a day, or in connexion with the syrup of the iodide of iron, 
or half a grain of the metallic iron (Pulv. Ferri). When the appetite 
has been very feeble, I have found that quinine, in the dose of a grain 
three or four times a day, at the age of three or four years, has restored 
it more rapidly than any remedy I have made use of. 

Before concluding my remarks upon the treatment of simple hooping- 
cough, I wish to state that cases of the disease occur not unfrequently of 
so mild a form, as to need absolutely no treatment other than the proper 
degree of attention to hygiene ; and that others again, more numerous 
than those just mentioned, will be met with, in which the only treatment 
necessary is the use, for a few days or weeks, of some mild expectorant and 
opiate at night to lessen the severity of the paroxysms. Out of 61 cases 
that I have seen in the last four years, I find that I gave nothing at all in 
10. In 5 I gave a few doses of alum occasionally. In 4 the only treat- 
ment was a little paregoric and syrup of ipecacuanha at night. 

In infants particularly it is proper to give as little medicine as possible, 
allowing the disease to go on without interference so long as it progresses 
safely. When, however, the paroxysms become very numerous and 
violent, exhausting the strength of the child and distressing its nervous 
system, we must make use of some remedy to allay the severity of the 
attacks. I have found the alum safe and effectual. At the age of two 
and three months, I have usually given from half a grain to a grain three 
times a day, taking care to suspend it for a day or two when it caused 
troublesome vomiting or purging, and then resuming it in diminished 
dose. This, or in some instances small doses of paregoric and syrup of 
ipecacuanha, constitute almost the only remedies I have made use of in 
the cases of infants. 

15 



226 HOOPING-COUGH. 

Treatment of the Complications. — If any of the diseases which 
have been mentioned as apt to occur during pertussis should arise, the 
treatment which is proper for them in their idiopathic form, must be 
adopted without regard to the hooping-cough, with the following reserva- 
tions : that care must be taken not to use means of too powerful and ex- 
hausting a nature, or such as have a tendency to irritate the organs with 
which they come in contact. For, it must be recollected, that after the 
complication is cured, the patient has still the original disease to go 
through with, and therefore requires all his strength ; and, moreover, the 
various organs of the body are predisposed by the very fact of the exis- 
tence of the original malady, to assume diseased action, should any 
irritation in the shape of a violent remedy be applied to them. 

The cases of bronchitis which came under my observation were treated 
in the simplest manner. The children were put to bed, the diet carefully 
regulated, the bowels gently opened with castor oil or syrup of rhubarb, 
and small doses of syrup of ipecacuanha or antimonial wine, with sweet 
spirits of nitre, were administered every two hours. Mustard poultices 
were applied once or twice a day to the interscapular space, and mustard 
foot-baths used every night, or more frequently, if the dyspnoea were con- 
siderable. If the bronchial secretions were very profuse, and the cough 
troublesome, the decoction or syrup of seneka was given in connexion with 
occasional doses of laudanum or paregoric. 

The complication of pneumonia was treated somewhat differently. In 
three of the cases, occurring in children seven and nine years and between 
two and three years old respectively, depletion was used : the eldest was 
bled at the arm, and the other two leeched upon the chest. In the fourth 
case, in a child between one and two years old, the treatment consisted in 
the use of tartar emetic, in the dose of the sixtieth of a grain every 
hour, for the first three days, and afterwards of syrup of ipecacuanha, 
spirits of Mindererus, and paregoric combined. In the three cases first 
mentioned, the treatment besides the depletion consisted in the adminis- 
tration of small doses of antimonial wine and nitre, in the manner pointed 
out in the article on pneumonia, in the use of small doses of Dover's 
powder, and of the foot-bath. They all recovered. 

When convulsions occur they must be treated according to the cause 
which produces them, and the constitution and present state of the child. 
If the patient be strong and sanguine, and not exhausted by previous 
sickness, the treatment should consist of depletion by venesection, or by 
leeches to the temples, or behind the ears; of cold applications to the 
head j the warm bath ) cathartics or purgative enemata ; and revulsives 
in the form of sinapisms, or of a small blister to the nucha. If, on the 
contrary, the patient is of delicate constitution, or exhausted by long ill- 



TREATMENT. 227 

ness, we must be content to resort to warm baths, revulsives, antispas- 
modics and anodynes, and stimulating enemata. 

Of the 10 cases of convulsions that came under my notice, 3 proved 
fatal. Two of the fatal cases occurred in children who had long been 
laboring under bronchitis that had baffled all treatment. Death took 
place within twenty-four hours from the appearance of the convulsions , 
which were in fact the result of the diseased condition of the lungs. No 
treatment further than the warm bath and sinapisms, was resorted to. In 
the third case, the convulsions came on in the seventh week of the disease, 
in a child who had been laboring for a number of days under severe 
bronchitis ; they ended fatally in seven hours. The treatment employed 
at the beginning of the fit was a warm bath, an enema and mustard plasters. 
After a few hours, solution of morphia with fluid extract of valerian were 
given by enema, cold was applied to the head, and a blister to the nucha. 
Of the favorable cases, one occurred in a boy five months of age, on the 
third day of a severe attack of bronchitis. The child was immediately 
placed in a warm bath, and large sinapisms applied over the front of the 
chest and upon the extremities, when the convulsions ceased. After this 
he was treated with half-grain doses of alum, repeated every three or four 
hours, mustard foot-baths and poultices, and small doses of wine of opium. 
On the sixth day of the attack, the third after the convulsive seizure, 
there having been no return of the convulsions, the bronchitis subsided 
with copious sweats and cold hands and feet, for which small quantities of 
brandy and water and wine-whey were used. The recovery was perfect. 
A second case occurred in a hearty boy nine months old, and seemed to 
depend on congestion of the brain, brought on by a severe fit of coughing. 
In this instance a venesection to a small amount was performed, the child 
was placed in a warm bath, and cold applied to the head. No return of 
the spasms took place, and the child recovered without difficulty. In 
another case the convulsion was caused by an attack of fever depending on 
dentition, and was treated by lancing the gums, by a warm foot-bath, and 
by the administration of a grain of calomel in a teaspoonful of castor oil. 
In a fourth case the convulsions were caused by pneumonia, and were 
managed by treating the pneumonia, except that at the moment of the 
attack a warm bath and a stimulating enema were made use of. In a fifth 
the convulsion, which was a short one, occurred at the onset of an attack 
of bronchitis. No particular treatment beyond what was necessary for 
that disease was required. In a sixth, in a boy nine months old, the con- 
vulsion occurred suddenly, was violent, and lasted fifteen minutes. The 
cause could not be ascertained. The only treatment used for the convul- 
sion was a warm bath. There was no return. In a seventh case, in a 
boy nine months old, a slight convulsion occurred during one of the 



228 HOOPING-COUGH. 

paroxysms in the fifth week. No treatment was necessary, as the attack 
was very short, and there was no recurrence of the symptoms. 

Hygienic Treatment. — This part of the management of the disease 
is of the highest importance, for it is by careful attention to its details, 
that the complications which constitute the chief danger of the malady, are 
to be prevented. In a considerable number of cases of pertussis, nothing 
more need be done than to insist upon strict attention to hygienic rules. 
The chief indications are to preserve the child from taking cold, and to pre- 
vent indiscretions in diet. The clothing ought to be warm, and during 
the autumn, winter, and spring, flannel should always be placed next to 
the skin. The child ought to be kept in the house during damp weather 
at all seasons, and whenever, during the winter season, it is intensely cold. 
The diet should be nutritious, but of easy digestion. All heavy, rich food 
ought to be absolutely forbidden during the continuance of the malady. 

Treatment op the Paroxysm. — It often happens that the paroxysms 
are so violent, that the child seems to be in imminent danger of suffoca- 
tion or of convulsions. This is especially true of infants. In six cases that 
I have seen, in infants under six months old, the kinks lasted so long, and 
the spasm of the larynx was so unyielding, that the children struggled as 
though laboring under tetanus; the countenance was disturbed and 
anxious ; the face and hands, at first flushed, became purple from deep con- 
gestion ; and on some occasions the breathing was suspended for several 
seconds, so that life seemed for the time in the greatest danger. The diffi- 
culty in these cases depends on the spasmodic closure of the glottis, which 
is, sometimes, no doubt, completely shut. I have never known these 
alarming symptoms of asphyxia to occur when the hoop has been clear 
and distinct, for when that is present, the larynx cannot be very tightly 
closed. 

When the symptoms above described occur in older children, these should 
be raised and supported in the sitting posture; when in infants, they 
ought to be held lightly in the arms, so that they may take any position 
which instinct prompts them to. At the same time cold water ought to 
be sprinkled from the fingers upon the face, the child should be gently 
fanned, or, if the weather be warm, taken to the open window, and if there 
be time, it is well to put the feet into mustard water. It has been recom- 
mended on such occasions to apply compresses dipped into cold water to 
the sternum. I would propose the trial of a means which my father found 
very successful in arresting tonic spasm of the respiratory muscles, in a 
case of laryngismus stridulus. This is the sudden application of a piece 
of ice wrapped in linen to the epigastrium. When the laryngeal spasm is 
very intense and obstinate, a small blister to the front of the neck, is useful 
in controlling it. 



CLASS II. 

DISEASES OF THE DIGESTIVE ORGANS. 
CHAPTER I. 

DISEASES OF THE MOUTH. 

I find myself much embarrassed in regard to the classification of the 
diseases of the mouth most proper to adopt. So much confusion reigns 
amongst authors as to their nature, and consequently as to their nomen- 
clature, that it is very difficult to reconcile the various discrepancies 
which exist. • After much consideration, however, I believe that the fol - 
lowing arrangement is the one best suited to the existing state of know- 
ledge upon these affections : 

1. Simple or erythematous stomatitis. 

2. Follicular stomatitis, or aphthae. 

3. Ulcerative, or ulcero-membranous stomatitis. 

4. Gangrene of the mouth. 

5. Thrush, or stomatitis with curd-like exudation. 



ARTICLE I. 

SIMPLE OR ERYTHEMATOUS STOMATITIS. 

This form of stomatitis consists of simple diffuse inflammation of the 
mucous membrane of the mouth, unattended by vesicular or pustular pro- 
ductions, by ulceration, or by membranous exudation. It is a disease of 
infrequent occurrence, except in the forming stage of other kinds of 
stomatitis, and of little importance, seldom requiring the attention of the 
physician. 

The causes of the disease are the introduction of irritating substances, 
such as hot drinks, and acrid or caustic preparations, into the mouth ; 
difficult dentition; and probably sympathy with disordered states of the 



230 APHTHA. 

stomach. It occurs not unfrequently as a secondary affection, particularly 
in the course of measles, scarlet fever, and small-pox. 

The symptoms of erythematous stomatitis are more or less vivid redness 
of the mucous membrane, sometimes diffused, and at others punctuated or 
disposed in patches; slight swelling of the same tissue; heat; and tender- 
ness to the touch, and also in the act of sucking or eating. The child is 
generally fretful and restless, and either loses its appetite, or refuses to 
nurse or take food freely, on account of the tenderness of the mouth. 
There are seldom any general symptoms except in secondary cases, in 
which they are those of the primary affection. 

The treatment is very simple. It consists in the use of some demulcent 
wash, as gum-water, sassafras pith mucilage, a little honey put on the 
tongue occasionally, and if the inflammation be at all considerable, in the 
application of some astringent preparation. This may consist of honey 
and borax, two or three parts of the former to one of the latter, or of the 
following wash, recommended by M. Bouchut : 

R.— Mel. Rosse, gi. 

Aluminis, gss. 

Aquse distillat., ^ss. — M. 

The application of any of the washes recommended is best made by 
means of a thick and soft earner s-hair pencil; or it may be done with a 
soft rag, which should be dipped in the wash, and then conveyed into the 
mouth on the point of the finger. The remedy ought to be used several 
times a day. 

If signs of gastric or intestinal disorder are present, they should be 
attended to. 



ARTICLE II. 

APHTEA 

Definition; Synonymes; Frequency; Forms. — The term aphthae 
ought to be restricted to the vesicular and ulcerous form of disease of the 
buccal mucous membrane, in which that tissue is covered with an eruption 
of vesicles which break, and are followed by small rounded ulcerations. 
Under this title writers formerly confounded the affection we are now con- 
sidering with ulcerative stomatitis and thrush. It is called by Billard 
follicular stomatitis, and by several other writers vesicular stomatitis. 

The frequency of the disease is very considerable. I shall describe 
two forms, the discrete and confluent. 



CAUSES — SYMPTOMS — DIAGNOSIS. 231 

Causes. — The only causes which seem to have been ascertained with 
any degree of certainty are early age and the process of dentition ) the 
contact of irritating substances, particularly stimulating and acrid articles 
of food, with the mucous membrane of the mouth ; and the existence of 
some morbid irritation of the digestive tube, especially of the stomach. 
The confluent form is often connected with severe general disease of the 
constitution. 

Symptoms ', Duration. — Aphthae begin in the form of small red ele- 
vations, having little white points upon their centres, which consist of the 
epithelium of the mucous membrane raised into vesicles. The vesicles 
are small in size, oval or roundish in shape, and of a white or pearl 
color. They soon break and allow the fluid which they contained to 
escape, after which there remains a little rounded ulcer, with excavated 
and more or less thickened edges, and surrounded almost always by a red 
circle of inflammation. The bottom of the ulcers is usually of a grayish 
color. There is seldom any diffuse inflammation of the mucous mem- 
brane in this disease. The number of aphthae varies in the two forms. 
In the discrete variety there are but few, whilst in the confluent form 
they are of course much more numerous. They generally appear first on 
the internal surfaces of the lips and gums, and then on the inside of the 
cheeks, edges of the tongue, and soft palate. 

The discrete form is generally accompanied by symptoms of slight dis- 
order of the digestive organs, consisting of thirst, acid eructations or 
vomiting, imperfect digestion, and a little constipation or diarrhoea. The 
confluent form, which is much more rare, especially in very young infants, 
usually coincides, as has already been stated, with severe general or local 
disease. 

The duration of aphthae is different in the two varieties of the affec- 
tion. The discrete form generally pursues a rapid progress, lasting, 
usually, from the beginning to the time of cicatrization, between four and 
seven days. Sometimes, however, when the vesicles are formed succes- 
sively, one after the other, the disease lasts much longer. The confluent 
variety pursues a much slower progress, and is much more difficult of 
cure. 

Diagnosis and Prognosis. — The diagnosis of discrete aphthae is not 
at all difficult, in consequence of their being isolated and succeeded by 
small and limited ulcerations. The confluent form, on the contrary, may 
be confounded with ulcerative or ulcero-membranous stomatitis, and with 
thrush. From the first-mentioned disease it may be distinguished, how- 
ever, by attention to the circumstances that that affection begins by small 
white patches, and not by pustules, as do aphthae ; that the ulcerations 
which follow the patches are covered with true pseudo-membrane ; and 



232 APHTHiE. 

that the white patches just spoken of appear first upon the gums, whilst 
aphthae generally begin upon the posterior surface of the inferior lip, and 
upon the tongue. From thrush it is to be distinguished by the facts that 
that disease commences by white points which are not pustular, and which, 
running together, form a creamy exudation, and by the absence or very 
small number of the ulcerations. 

Discrete aphthae constitute a very mild disorder. They always recover 
without much difficulty. The confluent disease is more serious, because 
its progress is much slower, its cure more difficult, and because it is often 
connected, as has been stated, with some other severe disease. 

Treatment. — Aphthae, particularly the discrete variety, require in 
general very simple treatment. The means to be employed are general 
and topical. 

The discrete variety usually requires only topical remedies, regulation 
of the diet, and when there are marked symptoms of gastric derangement, 
the exhibition of some mild emetic, or of a laxative dose. The local treat- 
ment should consist of applications of demulcent preparations, as the 
mucilages of slippery elm, sassafras pith, flaxseed, marsh-mallow root, 
quince seeds, &c, which are to be used pure when there is no pain, or with 
the addition of a few drops of laudanum or wine of opium, when the 
mouth is sore and tender; the aphthae ought to be touched occasionally 
with the mixture of borax and honey, or the aluminous preparation re- 
commended for simple stomatitis. The applications must be made several 
times a day with a camers-hair pencil, a pencil made of charpie or cotton, 
or with a soft rag covering the finger. When the ulcers which follow the 
vesicles fail to cicatrize rapidly under the above applications, or when they 
are numerous and painful, their cure may be very much hastened and the 
pain quickly relieved, by touching them lightly with a stick of nitrate of 
silver, or a piece of alum, sharpened to a point; or we may employ a pencil 
dipped into a strong solution of nitrate of silver, or into a mixture of one 
part of muriatic acid to two of honey. 

The general treatment of discrete aphthae need consist of nothing more 
than the prescription of a simple, unirritating diet in most of the cases. 
If, however, the digestive apparatus is deranged, the case must be treated 
according to the symptoms ; by antacids or a gentle emetic, when the 
tongue is foul and the secretions acid, and by the use of a mild laxative, 
as castor oil, magnesia, or rhubarb, when there is constipation. When 
diarrhoea is present, we should resort first to a small dose of castor oil or 
syrup of rhubarb, with the addition of half a drop to two drops of lauda- 
num, according to the age of the child, and afterwards to astringents and 
opiates, as will be recommended in the article on simple diarrhoea. 

The treatment of confluent aphthce must depend on their cause. The 



ULCERATIVE STOMATITIS. 233 

local treatment is the same as that for the discrete variety, except that 
cauterization should be resorted to at an earlier period. When they seem 
to depend upon a general morbid condition of the constitution, as con- 
genital debility, a scorbutic diathesis, or upon chronic affections of the 
digestive organs, they must be treated in the first place by properly 
regulated and nutritious diet, and by the exhibition of tonics and gentle 
stimulants, particularly iron, quinine, and small quantities of very fine 
old brandy ; and in the second case, in the manner which will be recom- 
mended for chronic derangements of the stomach and bowels, when I come 
to treat of the diseases of those organs. 



ARTICLE III. 

ULCERATIVE OR UL C E R -M E M B R A N U S STOMATITIS. 

Definition; Synonymes; Frequency. — This form of sore mouth is 
characterized by the secretion upon the mucous membrane of a plastic 
exudation in thick, yellowish, adherent patches, and by inflammation, 
erosion, or ulceration of the subjacent tissues. It is the same disease as 
the aphtha gangrenosa, and I believe the cancrum oris also of Underwood ; 
the ulceration of the mouth of Dewees and Eberle ; the stomatite couen- 
neuse, and the ulcerative and pseudo-membranous forms of the stomatite 
gangreneuse of M. Valleix ; the stomatite pseudo-membraneuse or diph- 
theritique of some writers; and the stomatite ulcero-membraneuse of MM. 
Billiet and Barthez. It is the disease described under the title of gan- 
grenous sore mouth by Dr. B. H. Coates (North American Surgical and 
Medical Journal, vol. ii., 1826), with the exception of a few cases which 
were what I shall treat of as gangrene of the mouth. It is treated of by 
Dr. Condie (Dis. of Chil, 2d edit., p. 142) under the title of gangrene of 
the mouth, and partly confounded, as it seems to me, with a much less fre- 
quent and vastly more dangerous disease, which I shall describe here- 
after as a separate affection under that name. 

Of the different titles given above, I prefer that of ulcero-membranous 
stomatitis, as most expressive of the distinctive features of the disease. 
This form of stomatitis is not very frequent in private practice, but some- 
times prevails extensively in hospitals, and other public institutions for 
children, where it often assumes an epidemic character. 

Causes. — The predisposing causes are epidemic influence, of the exis- 
tence of which I believe there is no doubt, according to some observers, 



234 ULCERATIVE STOMATITIS. 

contagion, which, however, has not as yet been positively shown, and bad 
hygienic conditions as to cleanliness, ventilation, food, clothing, and habi- 
tation. That it is epidemic, I have no doubt from my own experience, 
since I rarely see one case without soon meeting with others, while I 
sometimes pass several months without seeing a single example of the 
disease. I have also known it to be epidemic in a household, having on 
one occasion met with seven cases in two families of children residing 
under one roof, on two other occasions with three cases, and on several 
others with two. It is most frequent between the ages of five and ten 
years, though it may attack all ages, and is more common in boys than 
girls. It occurs during the convalescence from severe diseases, as pneu- 
monia, the eruptive fevers, typhoid fever, entero-colitis, and other affections 
of children. 

The exciting causes of sporadic cases are unknown, with the exception, 
perhaps, of the presence of a carious tooth in the mouth, and fracture or 
necrosis of the maxillary bones. 

Symptoms ; Course ; Duration. — The disease begins with slight 
pain and uneasy sensations in the gums, which then become swelled, red, 
bleeding when touched, and are soon after covered with a grayish, pulta- 
ceous exudation of varying thickness. The exudation extends from the 
gums to the internal surface of the lips and cheeks, and sometimes, but 
more rarely, to the soft palate, and even to the pharynx and nasal pas- 
sages. The plastic deposit occurs in the form of small, and slightly pro- 
jecting, yellowish patches, which approach each other, unite, and form 
bands of pseudo-membrane, somewhat uneven upon the surface, and adher- 
ing with considerable force to the tissue beneath. When the exudation 
is detached, the mucous membrane is found to be of a red or purple color, 
bleeding, and excoriated or ulcerated. The ulcerations which exist under 
the false membrane are of various depths, of a grayish, livid, or blackish 
color, with swelled, softened, and livid red, or bleeding edges. Those 
which are formed upon the inside of the lips are rounded in shape, whilst 
those seated in the angle between the lips and gums, are usually elongated. 
In mild cases of this affection, and these are particularly apt to occur in pri- 
vate practice amongst the easy classes of society, the local symptoms, though 
perfectly characteristic, are less severe than those just now described. 
The ulcerations are often few in number, amounting to four, five, or six 
upon the tongue, to a few scattered over the inner surfaces of the lips, and 
to some upon the gums, and especially about the necks of the teeth. The 
other symptoms are the same as those above mentioned, with the exception 
that they are milder in degree. 

When the disease is mild, and when it is properly treated, the false 
membranes are detached, leaving the mucous tissue merely excoriated, in 



SYMPTOMS — DIAGNOSIS — PROGNOSIS. 235 

which case it soon regains its natural condition ; or else the ulcers which 
exist beneath rapidly become healthy and cicatrize. In violent cases and 
in those badly treated, the inflammation, on the contrary, persists j the 
pseudo-membranes increase in thickness, or if detached, are formed anew ; 
the ulcerations become deeper ; the disease extends ) and the case lasts an 
indefinite period of time. 

Other symptoms, beside those we have mentioned, characterize the dis- 
ease. 

The breath is always more or less fetid, and in bad cases, almost gan- 
grenous. The salivary and sub-maxillary glands are generally more or 
less swelled, hard, and painful, and according to some authors, the sur- 
rounding cellular tissue is in the same condition, though this is denied by 
others. The movements of the lower jaw are stiff and painful in severe 
cases. Deglutition is not affected unless the disease extends to the pharynx. 
In violent cases there is usually a copious discharge of bloody serum, 
which flows from the mouth during sleep. When the ulcerations are deep 
and large, the tissues beneath are more or less swelled ; the swelling, how- 
ever, rarely assumes the hard, resisting, circumscribed characters, with the 
tense, smooth, hot, and shining appearance of the skin, which exists in 
true gangrene of the mouth. In most of the cases there is but little 
febrile reaction, especially at the invasion, though it sometimes increases 
afterwards if the disease becomes extensive. 

The disease begins, as already stated, on the gums, and unless limited 
to these parts, as sometimes happens, extends to the lips and cheeks. In 
many of the cases it attacks only one side of the mouth, and this is more 
frequently the left than the right. 

The course of the disease is usually rapid in epidemic cases, and in 
those which are properly treated. Where badly treated, on the contrary, 
it may last from one to several months, or terminate in gangrene of the 
mouth. 

Diagnosis ; Prognosis. — The diagnosis is, as a general rule, very 
easy, if proper attention be paid to the characteristic features of the dis- 
ease. It has, as already stated, been very often confounded with gangrene 
of the mouth. The method of distinguishing between the two will be given 
in full in the article on that disease. From thrush it is to be distinguished 
in the manner which will be pointed out under that subject. 

The prognosis is favorable in the great majority of the cases. Sporadic 
cases probably always terminate favorably. The epidemic disease, though 
rarely fatal, is sometimes so from its extension to the pharynx and larynx, 
or from its termination in gangrene of the mouth. I have seen a large 
number of cases in private practice, and have never as yet known one to 
become gangrenous or to prove fatal. Of upwards of 120 cases of this 



236 



ULCERATIVE STOMATITIS. 



kind, observed by Dr. Coates at the Philadelphia Children's Asylum, in 
a period of three months, all but one recovered (Loc. cit., p. 21). The 
cases which occur in the course of other diseases are not dangerous in 
themselves, but are so as the sign of great severity of the primary affec- 
tion. 

Treatment. — The treatment may be divided into general, and local or 
topical. The general treatment should consist in most of the cases in 
attention to the diet, which ought, in healthy and vigorous children, to be 
simple and unirritating, and in those who are weak and debilitated, nutri- 
tious and digestible. If the bowels are costive, or the child feverish and 
uncomfortable, a laxative dose may be given with advantage j or some 
simple diaphoretic, as nitre and water, or the neutral mixture, may be 
used through the day, and a warm pediluvium or an immersion bath given 
in the evening. When the constitution is feeble, and the child weak or 
anaemic, tonic remedies are indicated. The best is probably quinine, or 
one of the ferruginous preparations ; or the compound infusion of gentian, 
with addition of Huxham's tincture of bark, may be resorted to. If the 
inflammation be severe, and accompanied with tumefaction and tenderness 
of the glands and some febrile reaction, it would be proper to apply a few 
leeches to the neck. The best internal remedy, however, and indeed the 
only one of any kind that is necessary in a great many cases, is the chlo- 
rate of potash. This is spoken of in the highest terms by Dr. West, of 
London, who regards it almost as a specific. I have used it now in a large 
number of cases, and during the last four years, I have seldom found it 
necessary to employ any other means, excepting some mild cathartic dose 
where the bowels have been constipated, and a wash of borax or alum in 
honey of roses, or borax in simple honey. The symptoms have begun to 
amend in every case in from three to four or five days, and recovery has 
taken place in about a week or a little more. The dose is from two to 
three grains every four hours for a child three years of age, and four or five 
grains for one of nine or ten years. I have usually prescribed it in the 
dose of two grains four times a day, in a mixture of syrup of ginger and 
water, for children three or four years old. 

Prior to the discovery of the efficacy of the chlorate of potash in this 
affection, the local treatment constituted the only effectual and reliable 
means of removing it, and the most violent and painful applications were 
thought necessary and were made use of. Strong solutions of nitrate of 
silver, and pure or diluted muriatic acid, were frequently employed in 
severe cases. Now, however, these caustic substances may probably be 
entirely dispensed with, except in cases that show a tendency to assume 
the form of gangrene of the mouth. In ordinary cases the only local appli- 
cations that need be used, and these are not essential when the child 



TREATMENT. 237 

resists very much, are demulcent washes to keep the mouth clean ; 
to be employed in the manner recommended in the article on aphthae, 
and some mild astringent wash. This may consist of borax and honey, 
or borax and sugar, in the proportion of two or three parts of the former 
to one of the latter, or, what is in my opinion preferable to either of these, 
of a drachm of borax rubbed up with an ounce of honey of roses. 

Should the disease resist the treatment by the chlorate of potash and 
the simple washes just now recommended, we may employ the following 
combination, proposed by Dr. Dewees, and of which he says that it " has so 
far never failed us :" 



R. — Sulph. Cupri, . . 


. gr. x. 


Pulv. Cinch. Opt., 


• • m- 


Pulv. G. Arab., 


. . gi. 


Mel. Commun., 


• • 3y- 


Aquse Font., . . 


• • ^iij.— M. etft. sol 



The ulcerations to be touched with the solution twice a day, with the 
point of a camel' s-hair pencil. Or, we may resort to the following one, 
recommended by Dr. Coates (Loc. cit.), and. of which he says, that he 
" settled down, after various trials, in the employment of the following : 



R — Sulph. Cupri, gij. 

Pulv. Cinchonas, . . . . . . 3jss. 

Aquas, ^iv. — M. 



To be applied twice a day, very carefully, to the full extent of the ulcera- 
tions and excoriations/ 7 

MM. Billiet and Barthez recommend very highly the plan pursued by 
M. Bouneau at the Children's Hospital. This is to cleanse the mouth first, 
and then to apply dry chloride of lime (calx chlorinata of the pharma- 
copoeia), to the diseased surfaces. The application is made by means of 
a piece of rolled paper, or a stiff pencil, which is to be moistened and 
then dipped into the powder so that some may adhere, or with the finger. 
The surfaces are to be gently rubbed with the powder, and after a few 
moments' contact, washed clean with pure water. This is to be done twice 
a day, until the ulcerations assume a clean, healthy appearance, after 
which the following mouth-wash is to be employed : 

R. — Mucil. G. Acac, J ^i. 

Syrup Cort. Aurant., ^ss. 

Calc. chlorinat., "fyi. — M. 

The chief danger from the disease depends on the circumstance that it 
sometimes terminates in gangrene of the mouth, to be presently described. 



238 GANGRENE OF THE MOUTH. 

Any disposition to such a termination should be carefully watched, and 
the proper preventive means, consisting of local stimulating or caustic 
applications, with the internal use of stimulants and tonics, ought to be at 
once resorted to. 



ARTICLE IV. 



GANGRENE OF THE MOUTH. 



Definition ; Synonymes ; Frequency. — G-angrene of the mouth is 
an affection which occurs chiefly in children of debilitated constitution. 
It begins generally by ulceration of the mucous membrane of the cheek, 
which after a longer or shorter time, runs into gangrene, and extends 
rapidly to the gums ; after a few days, if the disease be not arrested, the 
central tissues of the cheek become thickened and indurated, an eschar 
forms upon the integument, and spreads in depth and width, until at 
last the cheek may be perforated, the whole side of the face and jaws 
destroyed, the teeth loosened, and the maxillary bones exposed and 
necrosed. It is known by a great variety of names : gangraenopsis, can- 
crum oris, gangrsena oris, kanker of the mouth, gangrenous erosion of the 
cheeks of Underwood; necrosis infantilis, gangrenous stomatitis, &c. It 
is a frequent disease in the hospitals for children in Europe, and a not 
uncommon one in institutions of the same kind in this country. It some- 
times prevails endemically in hospitals. It is a rare disease in private 
practice. I have never yet met with a case, excepting in public insti- 
tutions. 

Predisposing Causes. — The disease is nearly, but not exclusively 
confined to the period of childhood. It is most common between the ages 
of three and six years ; is very rare, but does sometimes occur in infants ; 
and is of nearly equal frequency probably in the two sexes. Unfavorable 
hygienic conditions constitute a strong predisposing cause. Children 
living in hospitals or any crowded institution ; those whose parents are 
poor or in want, and whose constitutions have been greatly deteriorated 
by long illness, by the tubercular diathesis, or by acute diseases, are par- 
ticularly apt to be attacked. It almost always follows upon some previous 
acute or chronic disease, particularly measles, or some other acute exan- 
theme ; pneumonia ; entero-colitis ; • hooping-cough j long-continued mala- 
rious fevers, &c. Guersent and Bache say (Diet, de Med., t. 28, p. 601), 
"The existence of some anterior disease is a necessary condition of 
gangrene of the mouth : we have never known it, nor has M. Baron, to 



ANATOMICAL LESIONS. 239 

occur as an idiopathic affection." It has been affirmed by some persons 
to be contagious , but this is exceedingly doubtful. The fact of its 
"occurring sometimes in an endemic form has already been referred to. It 
has been known also to prevail as an epidemic. 

The exciting causes can rarely be ascertained with any certainty. The 
only one which seems to have been proved to exist in some instances, is 
the exhibition of large doses of the mercurial preparations, and even this 
is questioned by some very good authorities. 

Anatomical Lesions. — Upon examination after death, it is found 
that the integument surrounding the mortified spot, soon runs into putre- 
faction. The lip or cheek in which the disease is seated is swelled, 
hardened, tense, and shining, of a purple or greenish color, and presents a 
deep, circumscribed engorgement. On the most prominent part of the 
swelling there often exists a rounded or oval, and distinctly limited eschar, 
of variable size, from that of a small bean to that of a dime, or a quarter 
or even half a dollar. In other instances the cutaneous slough is much 
larger, and extends irregularly to different parts of the face, to the chin, 
neck, eyelids, and even to the neighborhood of the ear, so as to occupy 
the whole of one side. Under these circumstances, the tumefaction is 
neither so considerable, nor so regular, as when the slough is smaller. 
The eschar is always black, and generally dry and parchment-like, and 
extends a third or two-thirds of a line in depth, or quite through the 
integument. The tissues beneath the skin are not generally implicated, 
though in some cases the eschar is detached, and there is a perforation of 
the cheek through which may be seen the alveolar processes. 

The mucous membrane of the mouth is always affected with mortifica- 
tion. The disease may be limited, so as to exist in the form of an elon- 
gated ulceration, of a dark grayish color, situated in the fold where the 
mucous membrane is reflected from the cheek to the lower jaw ; or, in a 
larger proportion of cases, it is seated on the internal surface of the cheek, 
opposite the interval between the alveolar processes. Sometimes the 
disease is much more extensive, and occupies all or a part of the internal 
surface of the cheek. In such instances the whole thickness of the 
mucous tissue is destroyed, and it presents upon its surface a blackish or 
brownish pultaceous slough, almost liquid in consistence, which may be 
scraped off with a scalpel, leaving beneath loose shreds of mucous mem- 
brane, without any trace of organization. The gums frequently parti- 
cipate in the disease, and are converted into shreds, or completely 
destroyed. 

The maxillary bones are sometimes, in severe cases, when the disease 
has extended to the gums, exposed, blackened, and even necrosed. The 
teeth are very often uncovered and loosened, and not unfrequently some 



240 GANGRENE OF THE MOUTH. 






are lost. The tissues between the skin and mucous membrane are found 
either hardened and infiltrated, or sphacelated to a greater or less extent. 
In the least severe cases, the fatty cellular tissue and the muscular struc- 
ture of the cheek are infiltrated with serum, but preserve their organiza- 
tion. When the disease is more aggravated, the gangrene extends to these 
tissues also, and always to those adjoining the mucous membrane first; so 
that the cellular structure beneath that membrane, and then the muscles, 
are infiltrated with a sanious fluid, and either in a state of sphacelus or 
tending thereto, whilst some of the adipose tissue beneath the skin is still 
merely infiltrated. In yet worse cases, the sloughs formed on the two 
surfaces of the cheek come into contact, and if their separation from the 
sound parts has taken place, a perforation is the consequence. 

The condition of the blood-vessels in the midst of the diseased parts has 
been carefully examined by MM. Rilliet and Barthez. These authors state 
that when the tissues of the cheek are merely infiltrated, the vessels remain 
healthy, permeable, and their parietes are scarcely or very slightly thick- 
ened. When the vessels run along the edge of the slough, they are still 
permeable, but their walls are thickened, and begin to assume the appear- 
ances of the mortified tissues. Lastly, when they traverse the centre of 
the eschar, they can still be traced out, but their canals are found oblite- 
rated by coagula, in the whole extent of the mortified parts ; or else the 
coagula occupy the vessels at their points of entrance into and exit from 
the slough, while between these points their walls are thickened, tend to 
assume the color and softness of the putrefied tissues, and their canals 
are filled with pultaceous gangrenous matter. The writers quoted do not 
suppose that the obliteration of the vessels is the cause of the sphacelus, 
since that change occurs only after the death of the surrounding tissues 
has already taken place. 

The disease very rarely occurs on both sides of the mouth at once, 
though this does occasionally happen. 

The submaxillar?/ glands are nearly always in their natural condition, 
but in rare instances are softened and engorged. 

Gangrene of the mouth never, or very rarely indeed, exists without 
lesions of other organs. Of these the most frequent are acute pulmonary 
affections, and after them, acute or chronic diseases of the gastro-intestinal 
tube, and then malarious fevers, pleurisy, pneumo-thorax, peritonitis, and 
nephritis. 

Symptoms ; Course j Duration. — The following account of the symp- 
toms of the disease is taken chiefly from the work of MM. Rilliet and Bar- 
thez. Gangrene of the mouth generally begins during the course or conva- 
lescence of some acute or chronic disease, by ulceration, aphthse, or phlyc- 
tenule, of the mucous membrane, and in rare instances, by oedema of the 



SYMPTOMS. 241 

substance of the cheek. At the same time the face is pale, and usually 
continues so throughout the disease ; the nostrils and eyelids are often in- 
crusted, and the latter infiltrated or sunken, and surrounded by bluish 
circles ; the lips are swelled and covered with scabs, or dry. The breath 
of the child is fetid from the beginning, and as the disease progresses be- 
comes gangrenous. There is but little fever at first, unless the case be 
accompanied by some acute disease : the pulse is commonly frequent and 
small in the beginning, rising gradually from 80 or 90 to 100 or 120, and 
becoming insensible towards the end ) in cases occurring in the course of 
other diseases, the pulse rises sometimes to 120 or 140, and is larger and 
fuller. The child is generally languid and quiet at first, or more rarely, 
cross and peevish. The strength maybe either lost entirely, merely dimi- 
nished, or the patient may retain a sufficient amount of force to sit up and 
observe what is going on around, and even to leave the bed the day before 
death. Half the children observed by Rilliet and Barthez, in whom 
this symptom was noted, sat up in bed until within a few days of the fatal 
termination. In most cases but little complaint is made of pain in the 
mouth, though in some it is said to be severe. 

The ulceration already spoken of as forming the first symptom of the 
disease, is generally of a grayish color, and resembles very closely that 
which exists in the ulcero-membranous form of stomatitis. It may be 
seated either on the gums, in the fold formed by the junction of the 
cheek or lip with the gum, or on the inside of the cheek, opposite the 
space between the alveolar processes. It may present a gangrenous 
appearance from the first day, or not until after two or three days ; or 
lastly, it may pass through the stages characteristic of ulcerative stoma- 
titis, and terminate in the affection under consideration. Dr. B. H. 
Coates (Loc. cit.) describes under the title of gangrenous sore mouth of 
children, the ulcero-membranous form of stomatitis, and a few cases of 
gangrene, and states that three or four children out of 120 affected with 
ulcerated gums, " suffered small spots of mortification, and one, by the 
delay arising from the tardy report of a nurse, suffered necrosis in a 
portion of an alveolus." 

The ulcerations just described assume the following appearances as the 
gangrenous nature of the malady developes itself. They become grayish, 
and then dark in color, bleed easily when touched, and are covered with 
pultaceous sloughs, exhaling a characteristic fetid odour. The gangrene 
extends to the neighboring parts, from the gum to the cheek, or from the 
cheek to the gum, and implicates at last the whole side of the mouth, or 
of the lower lip. At the same time the affected cheek or lip undergoes a 
circumscribed infiltration, which is at first rather soft, but becomes after- 
wards firmer, and forms at last a hard and rounded knot or tumor in the 

16 



242 GANGRENE OF THE MOUTH. 

centre of the cheek, which is now tense, shining, and pale, or marbled 
with purple spots, while the slough on the inside is of a brownish color, 
more extended in size, and sometimes surrounded by a dark ring. The 
hard tumor of the cheek just described, usually appears between the 
first and third day after the sphacelation of the mucous membrane, though 
in some instances, not until a later period. It is formed, as stated in the 
account of the anatomical lesions, by engorgement of the cellular and 
adipose tissues. The child, at this stage, is still able to sit up in bed 
and take notice, or shows evident signs of weakness and depression ; the 
face is swelled, and destitute of expression on the affected side ; a bloody 
or dark-colored saliva runs from the mouth, which is partially open ; the 
appetite is not entirely lost in all cases, the patient still demanding and 
taking food; vomiting is rare, but diarrhoea is almost always present; 
the thirst is generally intense ; the skin is warm and feverish, natural, 
or too cool, and almost always dry, the differences depending probably 
more upon the concomitant disease than upon the mouth-affection. The 
respiration is natural or altered according to the nature of the primary 
disease, which is, as already stated, in the majority of the cases, a pul- 
monary affection. The intelligence is generally undisturbed, though in 
some rare cases there is insomnia, delirium, or piercing cries. 

If the disease continues to progress, as it almost always does when it 
has reached the stage I am describing, there appears in many, but not all 
the cases (8 of the 21 observed by Rilliet and Barthez), a slough or 
eschar upon the most prominent and discolored part of the swelling of the 
integument of the cheek or lower lip. This generally makes its appear- 
ance between the third and sixth days of the disease, but in other cases, 
as early as the second, or not before the twelfth, or even later. The 
skin, at the point where the eschar is about to form, becomes purple, and 
then black ; sometimes a phlyctsena makes its appearance, which is very 
soon converted into a small, dry, black slough. This, if not limited by a 
process of separation from the living tissues, becomes larger and larger 
by the extension of the sphacelation, until it may, as already stated, 
embrace the whole side of the face. In grave and fatal cases, the gan- 
grene sometimes extends to all the tissues of the cheek, and meeting, at 
last, the disease which had commenced on the inside of the mouth, occa- 
sions a perforation through which may be seen the teeth, alveolar processes, 
and the whole interior of the buccal cavity. In such instances as these, 
one of which I saw in the Pennsylvania Hospital, the appearance presented 
by the child is, as may well be imagined, of the most sad and sickening 
nature. Even under these circumstances, however, with the cheek perforated, 
the edges of the opening irregular and covered with shreds of dead tissue, 
the gums destroyed, the teeth loosened, and the maxillary bones exposed, 



SYMPTOMS — COMPLICATIONS — DIAGNOSIS. 243 

blackened, and perhaps necrosed ; with a dark and fetid sanies flowing 
from the mouth or perforation, and a putrefactive smell infectiDg the air 
around, the child is said to retain, in some instances, its strength, so as to 
sit up in bed, ask for food, and drink with avidity. In other cases, on the 
contrary, the patient, at this stage, is exhausted to the last degree, and 
refuses both food and drink. During the closing stage of the disease, 
there is generally profuse diarrhoea, rapid emaciation, dry skin, small, 
rapid pulse, and at last death in a state of utter prostration. 

In favorable cases the recovery may take place in the early stage, 
before the integument becomes involved, and while the gangrene is limited 
to the mucous membrane, or at a later period, after the slough has sepa- 
rated. In the first instance the child generally recovers without deformity, 
though I saw one case in which necrosis of about an inch of the front of 
the inferior maxilla took place, without any loss of the soft parts. When 
the child recovers after the formation of the cutaneous slough, a very rare 
event, the gangrene ceases to extend, the eschar separates and is cast off, 
the edges of the opening assume the appearances of a healthy ulcer, and 
after a length of time, approach each other and cicatrize, leaving generally 
a large, uneven, discolored scar, like that of a burn, which remains through 
life a horrid deformity. 

The duration of the disease varies according to its termination. When 
this is unfavorable, which happens in much the larger proportion of cases, 
death usually occurs about the end of the first, or in the course of the 
second week, though it has been known to occur at a later period. In 
favorable cases the duration is commonly longer, particularly if a cuta- 
neous eschar has been produced, as the separation of the slough and 
cicatrization of the ulcer which remains, require a tedious and slow pro- 
cess on the part of nature. 

Complications are very apt to arise in the course of the disease. The 
most frequent is pneumonia. Guersant and Blache state that it exists in 
nine-tenths of the cases; Rilliet and Barthez found it in 19 out of 21; 
of the 19 it began in 8 during the progress of the gangrene, and appa- 
rently under the influence of the latter, whilst in the remaining cases it 
existed before, and acted perhaps as a predisposing cause to the affection 
of the mouth. Another and more dangerous complication is the occur- 
rence of gangrene in other parts of the body, particularly the soft palate, 
pharynx, oesophagus, anus, and more frequently the vulva and lungs. 

Diagnosis. — Some authors have described as identical affections, under 
the title of gangrenous stomatitis, the disease under consideration, and 
the one already treated of as ulcero-membranous stomatitis. This has 
been done particularly by M. Taupin, who is followed in his description 
by M. Valleix (Guide du Med. Prat, t. iv.) It seems clear to me, 



244 



GANGRENE OF THE MOUTH. 



moreover, that Dr. B, H. Coates, in his very valuable paper on the " gan- 
grenous sore mouth of children" (Loc. c&), and Dr. Condie, in his article 
on " gangrene of the mouth/' mingle in their descriptions the two dis- 
eases referred to. I cannot but think, however, that the differences 
between them as to frequency, symptoms, course, amenability to treat- 
ment, and termination, which are fully pointed out in the diagnostic 
table below, and lastly the example of MM. Baron, Billard, G-uersant, 
Rilliet and Barthez, and Dr. G-. B. Wood, fully warrant me in regarding 
them as different and distinct diseases. 

The diagnosis of gangrene of the mouth is, in most cases, very easy. 
The ulceration of the mucous membrane, followed by gangrene ; the deep- 
seated induration of the cheek, at first pale on the outside, then dark- 
colored, and terminating after a time in a characteristic slough; the 
course of the malady, and the nature of the general symptoms, will gene- 
rally prevent any difficulty in the recognition of the disease. 

From stomatitis it may be distinguished by attention to the points laid 
down in the following table, taken from Killiet and Barthez : — 



STOMATITIS. 

Begins by ulceration or by pseudo- 
membranous plastic deposit. 

Odor very fetid and sometimes gan- 
grenous. 

But little extension of the local lesion, 
which always retains the same appear- 
ances. 

But little swelling of the cheek or 
lips, or simply oedema of those parts, 
without deep-seated induration, tension, 
or unctuous appearance. 

Salivation rarely so considerable as 
to flow from the mouth ; when present 
sometimes sanguinolent ; never mixed 
with shreds of gangrenous tissue. 

Never an eschar on the exterior. 

Never complete perforation of the 
soft parts ; denudation of the bones 
never occurs ; loss of the teeth very 
rare. 

Course of the disease slow when left 
to itself ; recovery rapid under the in- 
fluence of treatment. 



GANGRENE. 

Begins by ulceration, which is some- 
times gangrenous from the first, or by 
oedema of the cheek. 

Odor always gangrenous. 

Considerable and rapid extension ; 
the tissues assume a peculiar dark- 
grayish tint. 

Extensive swelling and oedema of 
the cheek, with deep-seated induration, 
tension, unctuous appearance, purple 
spots. 

Salivation abundant ; constant es- 
cape of fluid, at first sanguinolent, af- 
terwards putrefactive. 

t 

Often an eschar upon the cheek or 
lips. 

Perforation of the soft parts fre- 
quent ; denudation of the bones con- 
stant ; loosening of the teeth constant, 
and their loss frequent. 

Course rapid, and fatal termination,' 
as a rule, when the disease is left to 
itself, and in spite of all treatment. 



Gangrene of the mouth may be confounded with malignant pustule. 



PROGNOSIS — TREATMENT. 245 

The method of diagnosis has been drawn by M. Baron in the following 
words: "Malignant pustule always begins on the exterior; affects the 
epidermis first, and extends successively to the corpus mucosum, chorion, 
and subjacent parts ; whilst, on the contrary, the gangrene under con- 
sideration attacks the mucous membrane first, then the muscles, and lastly 
the skin." 

Prognosis. — The prognosis of true gangrene of the mouth is exceed- 
ingly unfavorable. The great majority of the subjects perish in spite of 
all that can be done. Dr. Coates (Loc. tit. p. 14) says that a black spot 
on the outer surface of the swelling " has always been in my own expe- 
rience, the immediate harbinger of death. It is proper to state, however, 
that I have heard it said, that cases had recovered in this city, in which 
the gangrene had produced a hole through the cheek." Rilliet and Bar- 
thez state that " death is the ordinary termination of gangrene of the 
mouth; though there are instances of recovery on record." Of 29 cases 
analyzed by them, only 3 recovered. G-uersant and Blache {Loc. tit. p. 
596) state that unless arrested in the formative stage, it ends fatally 
almost constantly in from five to ten days, and frequently before perfora- 
tion has taken place. Of 36 cases observed by M. Taupin in the Chil- 
dren's Hospital, at Paris, not one escaped (G-uersant and Blache, Loc. 
tit. p. 597.) The authors of the Compendium cle Medetine Pratique, say 
of this disease (t. i. p. 632), " Death is the almost inevitable termination." 
Dr. Marshall Hall (Edin. Med. and Surg. Journ. xiv. p. 547), reports 
six cases of the disease, two of which followed measles, one repeated at- 
tacks of pneumonia, one fever (type not mentioned), one worm fever, and 
one typhus fever. All but one, the case occurring in the course of 
typhus fever, in a girl twelve years old, died. This girl recovered, 
with, however, falling-in of the right cheek, "a frightful chasm" on the 
left side of the mouth, and caries of a portion of the alveolar process, 
palate bone, and second molar tooth. Recoveries sometimes occur, how- 
ever, as in the case mentioned by Dr. Hall, after perforation, but nearly 
always with terrible deformities, with adhesions of the walls of the mouth 
to the jaws, with incurable fistulge, &c. 

The prognosis is more favorable in private practice than in hospitals. 
The favorable circumstances in any case are : good hygienic conditions ; 
vigorous constitution of the child; the absence of dangerous concomitant 
disease ; the continuance of appetite and strength ; and a disposition to 
limitation and separation of the slough. Unfavorable symptoms are : 
weak and debilitated constitution of the patient ; severe co-existent dis- 
ease ; prostration of the strength ; and extension of the sloughing process. 

Treatment. — The reader needs only to refer to the remarks on prog- 
nosis to be assured that no treatment as yet discovered promises much 
success. I would call attention also to the following statement, — that the 



246 



GANGRENE OF THE MOUTH. 



remarks about to be made apply only to true gangrene of the mouth, 
and not to all the cases described by some writers under the title of gan- 
grenous sore mouth or even that of gangrene of the mouth, since, as 
already stated, they confound together true gangrene and ulcero-mem- 
branous stomatitis. 

The treatment is divided into local and general. The local treatment 
recommended by the French writers, consists in cauterization of the 
sloughing parts with one of the mineral acids, with nitrate of silver, or 
with the actual cautery. This is the plan proposed by MM. Billard, Baron, 
Guersant and Blache, Barrier, Billiet and Barthez, Bouchut, and Valleix. 
The authors of the Bibliotheque du Medicin Praticien remark, however, 
that nearly all the patients subjected to cauterization die, and that of the 
small number saved, there are as many who had not been subjected to that 
treatment, as there are of those to whom it had been fully applied. They 
wonder, therefore, that recent authors continue to repose the same confi- 
dence in it, as did their predecessors. " For us," they say, " we are of 
opinion that cauterization exerts but slight influence, if it have any at all, 
and it is greatly to be desired that the zeal of practitioners might discover 
some more eflicacious remedy/' (Loc. cit., t. v. p. 551.) 

Is is very important to make use of the caustic application as early after 
the beginning of the sphacelus as possible, for if it be allowed to spread to 
any considerable depth or extent, there is scarcely a hope of arresting it 
by any means. G-uersant and Blache recommend pure nitric, sulphuric, or 
muriatic acid ) Billiet and Barthez propose the acid nitrate of mercury, 
or muriatic, sulphuric, or acetic acid ; M. Valleix proposes the treatment em- 
ployed by M. Taupin, which is to remove the pseudo-membrane and a part 
or the whole of the gangrenous eschar with scissors, to make some scarifi- 
cations upon the healthy parts, to apply pure muriatic acid, and after the 
fall of the slough, to make use of dry chloride of lime (calx chlorinata). 
The acid most generally employed is the muriatic. The local treatment 
proposed by Billiet and Barthez is the following : as soon as the ulcerations 
assume a gangrenous appearance, to touch them with abrush or sponge 
dipped into acid nitrate of mercury, or pure muriatic acid, the brush to 
remain in contact with the sloughs for a few instants, and then to be ap- 
plied rapidly around and on the parts beyond them. After this cauteri- 
zation, an application is to be made of dry chloride of lime (in the man- 
ner recommended in the article on ulcero-membranous stomatitis), which 
is to be left in contact with the sloughs for a few minutes, when the 
mouth must be thoroughly washed with a strong jet of water from a sy- 
ringe. The cauterization and use of the chloride of lime are to be resorted 
to twice a day, and the mouth washed three or four times in the interval 
with large injections of simple water, barley water mixed with honey of 



TREATMENT. 247 

roses, or better still, with a strong decoction of cinchona. If the case goes 
on favorably, and the sloughs separate, the cauterizations are to be sus- 
pended, and the chloride of lime alone employed. If, on the contrary, a 
slough forms on the outside of the cheek, a crucial incision must be made 
into it, and a brush charged with the same caustics introduced between 
the cuts; powdered cinchona is then placed in the openings, and retained 
there by a piece of diachylon plaster, or by pledgets of charpie, dipped in 
a solution of soda. This treatment is to be continued until the slough 
separates, when the edges of the wound, and all the diseased parts that can 
be reached, are to be cauterized. 

In applying escharotics to the mouth, certain general precautions are 
required, of which it is necessary to give some account. When they are 
used upon the inside of the cheek, a spoon must be introduced into the 
mouth, with the concavity directed towards the alveolar processes, in order 
to preserve the teeth and tongue from being touched. When the applica- 
tion is made upon the gums, the cheek should be drawn to one side by an 
assistant, and the tongue pushed out of the way with the finger, or a spoon. 
If the acid happen to touch the teeth or tongue, it must be instantly 
washed off. The mouth ought always to be thoroughly cleansed with 
water immediately after the cauterization, to remove any superabundance 
of acid. 

The kind of brush most suitable for the application of the mineral acids 
is one made of charpie, strongly tied to a solid handle. The sponge-mop, 
which is sometimes used, is made by fastening a small piece of fine sponge 
to the end of a stick. 

G-uersant and Blache recommend that the acid be applied to the slough 
every hour, until the sphacelus ceases to extend. They state that this 
plan is sometimes advantageous when the gangrene is confined to the gums 
only, but that it is generally powerless when the disease has extended to 
the cheek, or has implicated the deep-seated tissues. Under the latter 
circumstances, and when the inefficacy of caustics has been shown by trial, 
they propose the use of the actual cautery, as recommended by M. Baron 
and other distinguished practitioners, and which, they add, has afforded 
them some brilliant results in very bad cases. 

M. Barrier advises that we should accurately expose the diseased parts 
by crucial incisions, and apply the escharotic to all the parts forming the 
limits of the gangrene, in such a way that the tissues already disposed to 
slough shall be thoroughly cauterized, while those a little beyond are so in 
a less degree. 

The English writers, and those of our own country, seem rather less 
disposed than the French, to make use of powerful escharotics, and lay 
more stress upon the general treatment. Underwood, following Mr. 



248 GANGRENE OF THE MOUTH. 

Dease, of Dublin, advises that " the parts should be washed and likewise 
injected with muriatic acid, in chamomile or sage tea, and afterwards 
dressed with the acid, mixed with the honey of roses, and over all a carrot 
poultice." Dr. Symonds (Libr. of Pract. Med., vol. iii., p. 23), directs 
the cheek to be frequently rubbed with- a stimulating embrocation of cam- 
phorated oil and ammonia, on the first appearance of the swelling, and in 
the intervals to be kept moist with a tepid lotion containing muriate of 
ammonia and alcohol. On the slightest appearance of an eschar upon the 
interior of the mouth, it is to be touched with solid nitrate of silver, or 
strong muriatic acid. If sloughing have already commenced, the nitrate 
of silver lotion is said to be the best application. The mouth is to be fre- 
quently washed or syringed with a solution of chloride of soda, and when 
mortification has taken place, we are to endeavor to prevent it from spread- 
ing, by carrot or fermenting poultices. Maunsel and Evanson say that 
the early application of muriatic acid, undiluted, or mixed with one or two 
parts of honey, is the only efficient application in these forms of gangrene. 
Dr. Gerhard (Libr. of Pract. Med., vol. iii., Am. Ed., p. 24), says, "the 
best local applications are the nitrate of silver, if the slough be small in 
extent; if much larger, the best escharotic is the' muriated tincture of 
iron, applied in the undiluted state ; after the progress of the disease is 
arrested, the ulcer will improve rapidly under an astringent stimulant, 
such as the tincture of myrrh, or the aromatic wine of the French Phar- 
macopoeia." Dr. Dunglison {Pract. of Med., vol. i., p. 36) recommends 
the application with a brush, of a mixture of equal parts of creasote and 
alcohol, after incisions have been made through the gangrenous parts. Dr. 
Condie (Loc. cit., p. 150) states that he has found a strong solution of 
sulphate of copper (thirty grains to the ounce of water), applied very care- 
fully twice a day, to the full extent of the gangrenous ulceration, by far 
the most successful lotion. 

It seems to me very clear, after the study of the treatment recommended 
by the different writers quoted above, that the most important part of the 
local management of the disease, is the early application of some escha- 
rotic substance to the ulcerations, or to the mortifying parts; the best 
escharotic is probably pure muriatic acid. This should be made use of 
twice or three times a day, observing the precaution to wash the mouth 
immediately afterwards, with water by means of a syringe. Later in the 
disease, when it has extended to the skin, the use of escharotics, or of 
the actual cautery, is still recommended by many writers, but opposed 
by others. I confess I should be inclined to prefer at this stage, the use 
of muriated tincture of iron, as recommended by Dr. Gerhard, of strong 
lotions of sulphate of copper, of solutions of nitrate of silver of moderate 
strength, or of the dressings of muriatic acid and honey of roses, as pro- 



TREATMENT. 249 

posed by Underwood, in connexion with carrot and fermenting poul- 
tices, as recommended by Underwood and Symonds. Throughout the 
course of the disease the mouth ought to be frequently cleansed by wash- 
ing or injecting with solution of chlorinated soda, mixed with eight parts 
of water, which corrects at the same time the terrible fetor of the dis- 
ease. 

General Treatment. — All writers recommend the use of tonics, 
stimulants, and nutritious diet, unless the presence of high fever, or the 
state of the digestive organs, seems to contra-indicate their employment. 
Without personal experience on which to found such an opinion, but from 
a consideration of what I have seen most successful in other forms of gan- 
grene, as that following accidents and surgical operations in deteriorated 
constitutions ; from what proved effectual in a case of idiopathic gangrene 
of the vulva, in a child ten years of age, which came under my charge ', and 
from what is necessary in that analogous condition of the constitution which 
accompanies typhoid and cachectic diseases, I am induced to believe 
that the general treatment must be of as great or nearly as great impor- 
tance as the local, and that the steady and persevering use of tonics, stimu- 
lants, and of the most strengthening diet, should always be insisted on 
from the earliest period, whether fever be present or not. The quantity of 
stimulants and the amount of food, ought, it seems to me, to be measured 
only by the capacity of the digestive organs to receive and assimilate them. 
Of the tonics, the best is quinine, which may be given suspended in syrup, 
in doses of a grain four or five times a day, to a child three or four years 
old. The most suitable stimulants are very fine old brandy, Madeira wine 
given in considerable quantities, and, if the stomach is sure to receive it 
well, carbonate of ammonia, or better still, the aromatic spirits of harts- 
horn. The diet must consist of milk, made into punch with brandy, wine- 
whey, the yolks of eggs beaten up with wine, rich soups, animal jellies, and, 
if the child wish it, of tender meat finely minced. 

The room in which the child is placed ought to be large, if possible, and 
at all events, thoroughly ventilated. 



ARTICLE V. 

THRUSH. 



Definition; Synonymes; Frequency; Forms. — Thrush is a deposit 
upon the mucous membrane of the mouth, of a whitish or grayish-yellow 
exudation, of a soft, cheesy consistence, at first adherent, and afterwards 



250 THRUSH. 

spontaneously detached, and generally unaccompanied by ulceration of the 
tissue beneath. This constitutes the whole disease in some cases, no other 
lesion being discoverable -, whilst in other instances, and probably in a 
large majority, it is connected with some more or less serious general or 
local disorder. It is the disease described under the title of aphthae or 
thrush, by Underwood and Eberle ) of aphthae, by Dewees ; of erythematic 
stomatitis with curd-like exudation, by Dr. Condie, and of aphtha lactan- 
tium, aphtha lactamen, and aphtha infantilis of older writers. It is the 
muguet of the French. 

The frequency of the disease is very great in hospitals for children. It 
is common also amongst the children of the poor, and comparatively rare 
in the middle and upper classes of society. It occurs under two forms, 
the idiopathic or primary, and symptomatic or secondary. By the first 
is meant the form in which the affection of the mouth is the only percep- 
tible lesion ; by the second, that in which disease of other organs, or of 
the constitution generally, precedes the buccal exudation. 

Causes. — Predisposing Causes. — The disease occurs at all ages, but 
is by far most common during the first two months of life. Altered health 
from any cause, deficient ventilation, and want of cleanliness, strongly pre- 
dispose to the production of thrush. Much difference of opinion exists as 
to the nature of the connexion between enteritis and thrush, especially 
since the publication of the researches of M. Valleix, who thinks that the 
latter disease is almost always the consequence of the former, and who 
doubts the existence of purely local cases of thrush. MM. Trousseau 
and Delpech, on the contrary (Journ. de Med. de MM. Beau et Trousseau, 
January, February, April, May, 1845), report 14 cases out of 58, in 
which there was neither gastric nor intestinal complication, and others in 
which enteritis did not occur except as a consequence of thrush. They 
state, however, that though enteritis does not exist in all cases, and is a 
simple complication in others, it is sometimes the true cause, the sole origin 
of the disease. Again, Dr. Berg, in a very accurate and careful history 
of the disease (Brit, and For. Med. Rev., October, 1847, p. 429), in which 
he asserts and endeavors to show its cryptogamic nature, states " that both 
the local and general symptoms which accompany thrush in the child are, 
in most cases, immediate or secondary consequences of the presence of the 
parasite, and not to be regarded as the causes of that fungoid vegetation/' 
It is believed by many observers to be contagious. This opinion is ren- 
dered doubtful, however, by the assertions of MM. Baron, Billard, G-uer- 
sant, and Valleix (Loc. cit., t. iv., p. 63), that they have known children 
in health to be fed with the same spoon which has been used for others 
affected with the disease, without their contracting it. M. Bouchut, on 
the contrary, and Dr. Berg (Loc. cit.), both of whom believe in the cryp- 



CAUSES. 251 

toganiic nature of thrush, assert it to be contagious. Dr. Berg is of opi- 
nion that it is " conveyed from one patient to another by sporules or frag- 
ments of sporules, in the dried state, floating in the atmosphere, but that 
it still more frequently is propagated by the bottles from which children 
with thrush have been fed, or by the nipple, especially where, as in many 
hospitals, two children are suckled by one nurse/' This gentleman made 
many experiments in order to decide this question, all of which proved 
favorable to the idea of contagion. 

Of various predisposing causes which have been cited as productive of 
the disease, the ones most generally admitted are the use of artificial 
diet, particularly one consisting of farinaceous substances, and, in children 
who are suckled, an unhealthy state of the nurse's milk. To show the 
truth of these assertions, I make the following quotations. Underwood 
says : " A principal remote cause of this disease seems to be indigestion, 
whether produced by bad milk, or other unwholesome food, or by the 
weakness of the stomach." Dewees remarks that " children fed much 
upon farinaceous substances, are especially exposed to the attacks of this 
disease, particularly when their food is sweetened with brown sugar or 
molasses." Dr. Eberle says : " Unwholesome and indigestible nourish- 
ment, and over-distension of the stomach, during the early stages of 
infancy, almost inevitably lead to the occurrence of aphthae (thrush). 
Bad and old milk, and thick farinaceous preparations sweetened with 
brown sugar or molasses, are especially apt to give rise to the disease." 
Much influence is ascribed by Dr. Berg to the operation of artificial food 
in favoring the growth of aphthce. M. Valleix (Loc. cit., p. 60), who has 
studied the subject with the greatest care and attention, says that amongst 
the hygienic conditions which may act as predisposing causes "one alone 
has seemed to me to exert a positive influence, and this is improper ali- 
mentation." He adds that since the publication of his " Clinique," he 
has several times met with cases of thrush, " and I have always found 
that the children had been put upon feculent diet. On the other hand, 
I have never known a child to have the disease, who had been suckled 
exclusively during the early months of life." MM. Trousseau and Del- 
pech, in the very valuable paper on muguet (thrush), already quoted, 
say : "We would be justified, therefore, in asserting, that we have never 
known an infant to die of thrush, who had been suckled at a healthy 
breast, or whose health had not been dangerously compromised by other 
causes." To show in another mode the influence of this cause, I will 
state that of 29 cases of the disease observed by these gentlemen in 
children who were suckled, only 7, or one-fourth, died ; whilst of 22 in 
those who were not suckled, 17, or more than three-fourths, died. 

Season exerts a considerable influence upon the production of thrush, 



252 THRUSH. 

as M. Valleix found that more than half the cases occurred during the 
three warmest months of the year. 

Exciting causes — The deprivation of the breast, and a consequent resort 
to artificial diet, particularly one consisting of farinaceous substances, is 
probably much the most frequent exciting cause of thrush. An unhealthy 
state of the milk of the nurse will also act as an exciting cause. I have 
met with two cases of the disease, one of them fatal, which appeared to 
depend upon the latter circumstance. Dr. Berg believes that prolonged 
sleep from any cause disposes to the disease, by favoring the growth of 
the parasite, or by so changing the secretions of the mucous membrane of 
the mouth, as to render them important agents in augmenting the dis- 
order. An acid state of the buccal secretion is cited as a cause by many 
authors, and is clearly proved to exist in a great many instances. 

Anatomical Lesions. — The characteristic exudation is formed upon 
the mucous membrane of the mouth, pharynx, oesophagus, and in very 
rare cases, of the stomach and intestines. It is a curious fact, and a very 
important one, insisted upon by MM. Trousseau and Delpech, and other 
observers, that the false membrane never extends to the nasal or air- 
passages ; and they call attention to the singular difference in this respect 
between the affection under consideration and diphtheritic inflammation, 
which attacks almost exclusively the nostrils, pharynx, larynx, and bron- 
chia. 

Lesions of the digestive mucous membrane are met with in nearly all 
the cases. M. Yalleix states that softening of the gastric mucous mem- 
brane is almost constant, and that it is often accompanied by redness and 
thickening. The authors cited above are of opinion that the gastric 
lesions have been greatly exaggerated, and assert them to be much 
the same as exist in other diseases foreign to the digestive apparatus. 
Various morbid alterations of the mucous membrane of the intestines 
exist in nearly all fatal cases. This fact is acknowledged as well by MM. 
Trousseau and Delpech, who deny the invariable connexion of these 
alterations with thrush, as by M. Yalleix, who asserts the connexion 
almost without reserve. In nearly all cases the mucous membrane of 
the large intestine presents some of the following lesions, which are men- 
tioned in the order of their frequency ; thickening, injection, softening, 
or ulceration. In the ileum are found, in a great many cases, injection, 
softening, or thickening of the mucous membrane, unusual development 
of the mucous follicles, and tumefaction and ulceration of the glands of 
Peyer. 

In severe symptomatic cases a certain amount of erythematous inflam- 
mation is commonly found upon the skin of the buttocks and thighs, and 
ulcerations sometimes exist upon the inner ankles. Traces of inflamma- 



ANATOMICAL LESIONS — SYMPTOMS. 253 

tion sometimes, but very rarely, exist in the membranes of the brain, and 
the lungs not unfrequently present the lesions of secondary pneumonia. 
Before leaving this part of the subject, I may remark that in the few 
cases I have met with in private practice, no ulcerations occurred upon 
the malleoli, and the erythema was observed only in the neighborhood of 
the anus. 

Dr. Dewees describes the autopsy of a child who died about the end 
of the first month of life, of what he designates as aphthae. The lesions 
coincide so closely with those which are characteristic of thrush, that I 
will quote the description, in order that the two may be compared together 
by the reader. " We found the whole tract of the oesophagus literally 
blocked up with an aphthous incrustation, to the cardia, and there it 
suddenly stopped. The inner coat of the stomach bore some marks of 
inflammation, as did several portions of the intestines ; but not a trace of 
aphthae could be discovered below the place just mentioned." In the 
previous description of the case, he says that coat after coat of aphthae 
were thrown off, and each new crop appeared to be more abundant, and 
less amenable to remedies. (Dewees on Children, p. 304-305.) 

Dr. Eberle says : " I have myself had an opportunity of examining the 
body of an infant, that had died of this disease (aphthae or thrush). In 
this case the aphthae were very distinct, throughout the whole course of 
the oesophagus. The stomach and bowels presented nothing that bore 
any resemblance to this eruption ; but there were decided marks of in- 
flammation in the mucous membrane of the small intestines, with a vast 
number of minute superficial ulcerations, and larger patches of softening 
of this tissue, throughout the colon, and lower part of the rectum." 
(Diseases of Children, p. 172-173.) 

Symptoms. — I shall first describe the characters of the exudation, and 
then proceed to the consideration of certain general and local phenomena 
which exist to a greater or less extent in both forms of the disease. 

The mucous membrane of the mouth is often somewhat red, dry, and 
tender for a longer or shorter time (generally from one to three days), 
before the appearance of the exudation, and at the same time the papillae 
of the tongue swell and become protuberant. Next the exudation shows 
itself in the form of small, whitish points, sometimes on the tongue first, 
and in other cases on the inside of the lips, whence it extends to the 
cheeks, in idiopathic mild cases, and to the roof of the mouth, soft palate, 
pharynx, and oesophagus, in the grave symptomatic form. The points of 
false membrane first deposited, rapidly increase in size and thickness, so 
that in from one to three or four days, they assume the form of large 
patches, or a continuous membrane, which covers the whole or a conside- 
rable portion of the cavity of the mouth. When the exudation is recent, 



254 



THRUSH. 



it is thin, and its surface smooth ; Then, on the contrary, it has been 
longer deposited, it becomes thicker, and its surface is rough. It is at 
first of a milk-white or pearly hue, but when undisturbed assumes a 
grayish or yellowish color. It is soft in consistence, breaking down under 
the finger like cheese, and presents no traces of organization to the naked 
eye. It adheres to the mucous membrane with considerable tenacity, at 
first, but becomes looser after awhile, and is detached spontaneously at 
last without any lesion of the tissue beneath. 

The foregoing description applies to the exudation as it appears to the 
unassisted eye. I pass next to give an account of the characters it 
presents, when subjected to microscopical examination. These are such 
as have induced several observers to assert that the deposit consists of a 
true cryptogamic growth. Dr. Berg (Joe. cit.) states that the white 
coating of the exudation consists of epithelium, thickened by the swelling 
of its constituent cells ; from the epithelium there springs a parasitic 
fungus in greater or less quantity, so that the chief portion of a patch of 
aphthag (thrush) is composed either of epithelium or else of the parasitic 
growth. Under a magnifying power of from 200 to 300 diameters, an 
aphthous crust is seen to consist of epithelial cells, with a more or less 
interweaved coat of fibres, and a variable number of spherical or oval 
cells, without any sign of exudation-corpuscles, but only a small quantity 
of molecular albuminous deposit. " We can often trace the successive 
development of these cells from a spherical one of the smallest size, to an 
oval cell, and thence to a filament ; and we have no doubt ourselves that 
the smaller cells are sporules, out of whose development the larger oval 
cells are formed, and finally, the filaments in the same manner as has 
been observed in other fungoid growths of this nature." Numerous 
projecting fibrils are observed in the circumference of an aphthous crust 
when submitted to the microscope, but these are rendered infinitely more 
clear by a weak solution of potash, which dissolves the albumen, and 
renders the cells of the epithelium transparent, while, at the same time, 
it diminishes their intimate cohesion, and the network of vegetable fibres 
is more plainly seen. " These fibres are cylindrical, with sharply-defined 
dark edges, and their centres are transparent in transmitted light; they 
are generally equal in thickness, but at times they are, as it were, knotted 

together, and divided by distinct walls of separation In 

their interior, these fibrils often exhibit nucleated cells; occasionally 
these are very numerous, and of small size, but at times they are larger. 
In their course the fibrils divide into numerous branches, whose diameter 
is not less than that of the original stem, and I have occasionally observed 
these ramifications to increase in thickness, at their free extremity, and 
to terminate in a club-shaped end with a species of cell. From the sides 



SYMPTOMS. 255 

of the fibrils spring numerous sporules forming a point of departure for 

new ramifications Careful investigation has shown us that 

these cells are placed upon the sides of the fibrils, and in particular that 
they are congregated around the terminations of the latter. It must 
therefore be admitted that the cells and the fibrils are both constituent 
parts of one and the same organization. When this growth vegetates 
undisturbed, its fibrils penetrate between the layers of the epithelial cells, 
but do not extend deeper than the inferior layer, though they spread 
laterally in every direction. On the free surface of the epithelium, the 
ramifications rise above the surface, exhibiting at the same time an abun- 
dant fructification, which gives a yellowish hue to the exterior." 

I regret very much that my limits are such as prevent me from giving 
some account of the various facts and arguments brought forward by Dr. 
Berg, to prove the truth of his opinion, that the exudation of thrush is a 
parasitic growth or vegetation, having the epithelium of the mucous 
membrane for its soil. I must refer the reader to the very interesting 
review of Dr. Berg's work, from which we have made the above quota- 
tions, and to the work of M. Bouchut on the diseases of new-born children, 
for further accounts of the cryptogamic theory of thrush. 

Symptoms of the mild form of thrush. — This form is the one most 
frequently met with in private practice. It is mild in all its characters, 
and often presents no other symptoms than those connected with the 
mouth. These are heat and dryness, with tenderness of that part. The 
tenderness is shown by the child's crying and jerking the head backwards 
when the finger is introduced into the mouth, whereas in health the 
infant will almost always seize the finger and suck it with considerable 
force. It is shown also by the refusal to take the breast, or by the 
difficulty with which it is done, the child occasionally letting the nipple 
drop with a cry of pain, then seizing it again, and again letting go with 
fretting or screaming. In some of the cases there are various signs of 
disorder of the digestive tube, which are, however, seldom severe. They 
consist of slight diarrhoea, the stools being at first yellow, and afterwards 
green and acid, of occasional vomiting, of attacks of colicky pain, and 
sometimes of feverishness. To show how frequent is the occurrence of 
diarrhoea in thrush, and to prove also that it is not a necessary accompa- 
niment of the disease, as has been supposed by some persons, I will quote 
the fact mentioned by Dr. Berg, that of 115 cases, in only 29 did the 
stools retain the normal yellow color throughout the whole course of the 
disease ; while in the remaining 86 green evacuations appeared simulta- 
neously with the invasion, or supervened at a later period. We may cite 
also the cases reported by Trousseau and Delpech, of which only 14 out 
of 58 presented neither gastric nor intestinal complications. 



256 . THRUSH. 






The amount of exudation is generally small in this form, and it rarely 
extends behind the soft palate. The duration is usually between four 
and nineteen days, the average being about eight or twelve. The termi- 
nation is almost always favorable. 

Grave form. — It is under this form that the disease is most apt to 
occur in public institutions for children, and particularly in foundling 
hospitals. That it sometimes occurs also in private practice, will not be 
doubted, I think, by any who will read with care the descriptions of 
the disease given by Underwood, Dewees, and Eberle. I have myself 
met with two fatal cases in private practice, which presented all the 
symptoms described by M. Valleix, as characterizing those observed by 
him in the foundling's hospital at Paris, with the single exception of the 
ulcerations upon the internal malleoli. They were both children of 
parents who had every comfort at their command. One died at the age 
of four weeks, in consequence of the attempt to rear it on artificial diet. 
The other perished when six weeks old, apparently from some unhealthy 
condition of the mother's milk, which seems the more probable from the 
fact that the same mother had previously lost two children under pre- 
cisely similar circumstances ; all the children of this person were born 
vigorous and hearty, and did well for a short time, but soon after the 
birth, the nipples of the mother became dreadfully excoriated, the diges- 
tive organs of the infant began to give way, and death finally occurred 
with all the symptoms of fully-developed thrush. I can surmise now, 
though no examination was made at the time, that the cause of the disease 
was a continuance of colostrum granules in the mother's milk. 

The most important symptoms of the grave form are the buccal exuda- 
tion, various abdominal symptoms, particularly diarrhoea, vomiting, and 
colic, and more or less marked fever. The order of succession of the 
symptoms in severe thrush is not always the same. In most of the 
cases, the first symptom observed is probably diarrhoea, which is soon 
followed by fever, and in a few days by the appearance of the false mem- 
brane in the mouth. In a smaller number of instances the buccal exuda- 
tion is the first symptom observed. The characters of the exudation are 
much the same as those observed in the mild form of the disease, except 
that the membrane is thicker, covers a larger portion of the mouth, and 
generally extends to the pharynx and oesophagus. In addition to the 
plastic deposit, there sometimes exist, especially in very bad cases, ulcera- 
tions upon the roof of the mouth, frsenum linguae, and gums. These are 
generally few in number, and either confined to the mucous tissue, or 
they may extend to the fibrous texture beneath ; the surface upon which 
they rest is generally softened in consistence ; their edges are irregular, 
soft, and of a whitish or reddish color. The heat of the mouth is not 



SYMPTOMS. . 257 

generally increased, except in very severe cases; the mouth is moist at 
first, but afterwards becomes very dry, and, from the refusal to suck the 
finger when it is introduced between the lips, and the difficulty with 
which the acts of suckling or feeding are performed, is evidently tender 
and painful. 

The symptoms depending on the enteritic affection, are tenderness of 
the abdomen, diarrhoea, vomiting, and fever. The abdomen is usually 
distended by flatulent collections in the bowels, and is more or less painful 
to the touch, particularly in the right iliac fossa and epigastrium, and in 
severe cases over its whole extent. At the same time, the child evidently 
suffers from colicky pains, as shown by restlessness, by uneasy twisting 
movements of the trunk, by kicking of the limbs, and by crying, particu- 
larly just before, or at the moment of the evacuations. The appetite is 
usually diminished or entirely lost. The diarrhoea comes on gradually, 
the stools retaining their natural color at first, and being merely thinner 
and more frequent than natural. As the case progresses, they become 
more and more liquid and numerous, and almost invariably of a bright 
green color, and very acid. The green color of the discharges, and their 
highly acid condition, is noticed by all observers. Vomiting occurs in 
many of the cases, but is less frequent than diarrhoea. In some instances 
it is very obstinate and distressing, causiDg the rejection of whatever 
alimentary substances the child may take. Under these circumstances it 
has often been observed to coincide with the presence of a great deal of 
exudation upon the base of the tongue and soft palate, which has been 
supposed to act as its exciting cause. In other instances it is not so 
frequent, and as the matters ejected consist of greenish or yellowish bile, 
while at the same time the epigastrium is very sensible to pressure, this 
form of vomiting has been thought to depend upon gastritis. 

Fever exists in most cases, from the time that diarrhoea makes its 
appearance, and sometimes at an earlier period. It is at first moderate, 
but as the case goes on, often becomes intense, the pulse rising gradually 
from 80 to 90, or 120, 140, and even 160. The heat of the surface, espe- 
cially of the abdomen, is much increased, and accompanied by dryness. 
The feverish condition of the system is shown also by the restlessness and 
fretting of the child, and often by loud, frequent crying. When the 
exudation extends into the pharynx, the cry usually becomes hoarse and 
indistinct. 

There are two other symptoms which occur in the course of thrush, 
about which some discussion has arisen. These are the appearance of an 
erythematous redness about the anus, and upon the buttocks, genitals, and 
upper parts of the thighs, and ulcerations upon the internal malleoli. The 
erythema is stated by M. Valleix to precede the other symptoms in the 

17 



258 THRUSH. 

greater number of instances, whilst MM. Trousseau and Delpech deny the 
correctness of the assertion, and observed it to follow the diarrhoea in the 
majority of their cases. It seems to me that the latter authors are correct 
in ascribing the erythema to the irritation produced by the contact of the 
urine with the skin, which is predisposed by the cachectic state of the con- 
stitution, to take on inflammation from causes which would not affect it in 
its healthful condition. The erythema is sometimes followed by papulse, 
vesicles, blebs, and ulcerations, all of which probably depend upon the 
cause just referred to. The malleolar ulcerations are ascribed to the friction 
of the ankles against each other, a cause sufficient to produce such an effect 
in a broken down, diseased constitution, though insufficient in a healthy 
one. I may mention that I have seen the erythema several times in pri- 
vate practice, but never the malleolar ulcerations. 

During the acute period of the disease, the strength of the child is not 
much diminished, but as the case approaches its termination, if no favorable 
change takes place, the patient becomes weak and exhausted; the face 
assumes a pale and sallow look ; the features are sharp and defined, and 
the eyes dull and surrounded by bluish circles. At the same time the 
whole body becomes emaciated, the skin loses its elasticity, and hangs in 
folds or wrinkles upon the limbs, and the surface assumes a dark and 
dingy hue. As the fatal termination approaches, all restlessness ceases, 
and the child lies profoundly still, or only moves the mouth from time to 
time, or utters a faint cry; the diarrhoea diminishes, and the vomiting 
generally ceases ; the pulse becomes very rapid and weak, the extremities 
cold, and death occurs in the midst of profound quiet, or after a few slight 
convulsive movements. The duration of this form of the disease is very 
uncertain. It is often less than that of the mild form, since many chil- 
dren die in the first five days after the appearance of the exudation. In 
other cases it is much longer, from a few weeks to two months. Relapses 
are not uncommon. 

Before closing my remarks upon the symptoms, it is proper to state that 
the disease sometimes occurs at the termination of acute local affections, as 
pneumonia, bronchitis, or pleurisy, under which circumstances, there will 
be, in addition to the symptoms peculiar to thrush, those of the malady 
which preceded it. 

Nature of the Disease. — It is impossible, it seems to me, to determine, 
at present, whether thrush is, as M. Valleix asserts, a general disease, of 
which enteritis and the consequent buccal exudation are merely principal 
phenomena; whether, as MM. Guersant and Blache suppose, it is a super- 
ficial inflammation of the digestive mucous membrane, attended with a 
peculiar exudation as an effect; or whether, as supposed by Gruby, 
Bouchut, and Berg, it is a true cryptogamic or parasitic growth. Fortu- 



DIAGNOSIS — PROGNOSIS — TREATMENT. 259 

nately, the solution of the question is of no very great practical importance, 
as the causes of the disease, its phenomena, its prophylactic and curative 
treatment, are all ascertainable by careful observation, without a reference 
to either of these suppositions. 

Diagnosis. — The diagnosis of thrush is rarely difficult. Aphthae differ 
from it in their vesicular nature during the formative stage, in the ulcera- 
tions which follow the vesicles, and in the absence of false membranes. 
From ulccro-membranous stomatitis it may be distinguished, by the forma- 
tion in that disease of false membrane in layers from the beginning ; by 
the presence of ulcerations ; by the spongy, bleeding state of the gums ; by 
the fetid breath ; and by the absence of the abdominal symptoms which 
exist in thrush. 

Prognosis. — The prognosis must depend, in great measure, upon the 
circumstances under which the disease occurs. In private practice, and 
whenever the patients are suckled by their own mothers, or by healthy 
nurses, it is seldom a dangerous affection. But in foundling hospitals, on 
the contrary, where the children are mostly brought up on hand,. it is one 
of the most fatal maladies to which children are subject. The prognosis 
varies according to the form of the disease. The mild form is rarely 
fatal, while the grave form is fatal in the great majority of the cases. 

To show the frightful severity of the disease under certain circum- 
stances, I may mention that of 140 cases which occurred in the wards of 
M. Baron, at the Foundling's Hospital of Paris, only 29 recovered; while 
of 22 cases observed by M. Valleix, in the same hospital, but two reco- 
vered (Yalleix, Loc. cit. p. 74). Again, M. Bouchut states that of 42 
cases observed by himself, at the Necker Hospital, 14 were of the idio- 
pathic (mild) form, all of which terminated favorably; and 28 of the grave 
or symptomatic form, of which 20 died, and 8 left the hospital still labor- 
ing under the disease. Of the 20 fatal cases, 12 presented the lesions of 
chronic entero-colitis, 4 of acute entero-colitis, 3 of pneumonia, and 1 of 
hydrocephalus. It may be stated, in conclusion, that the danger is greatest 
in private practice, when the attack occurs in a child fed on artificial diet ; 
when there is reason to suspect an unhealthy state of the nurse's milk ; 
and in proportion to the extent and quantity of the exudation, its resist- 
ance to treatment, and the severity and obstinacy of the abdominal 
symptoms-. 

Treatment. — Prophylactic Treatment. — The most certain means of 
preventing thrush are evidently to procure for the child a full, healthy 
breast of milk, to give it a good habitation, to secure for it perfect cleanli- 
ness, and to' attend properly to its clothing. When it is impossible, from 
any cause, to obtain a nurse for the child, the diet ought to be most care- 
fully regulated as to quality, quantity, and times of administration. 



260 



THRUSH. 



General Treatment. — It seems to me that the successful manage- 
ment of thrush must depend much more upon judicious regulation of the 
hygiene of the child, than upon any therapeutical system that can be 
devised. The most frequent cause of the disease is, as we have seen, arti- 
ficial diet, or an unhealthy state of the nurse's milk. It is reasonable to 
conclude, therefore, that attention to the removal or mitigation of these 
and other unfavorable hygienic conditions, constitutes one of the most 
important indications of treatment. 

If a child who has been attacked with thrush is suckled exclusively, the 
milk of the nurse ought to be subjected to chemical and microscopic exa- 
mination, and should it be found to present unhealthy characters, another 
nurse ought to be procured as soon as possible. In all such cases the 
nurse must pay strict attention to her diet, avoiding all articles which she 
knows or suspects to disagree with her, and all very rich dishes. Dewees 
recommends that she should abstain from most common vegetables, except 
rice, and from all kinds of liquors, especially the fermented. 

When the disease occurs in a child who is nursed and fed alternately, 
and the remark about to be made applies still more strongly to one fed 
entirely upon artificial diet, the most important remedy in the case is to 
procure a good wet-nurse. This is far better than any medical treatment 
that can be instituted. Often, however, it is impossible, and under such 
circumstances, the regulation of the diet of the infant ought to be attended 
to with the utmost care by the physician himself, who should specify its 
material, quantity, and mode of preparation. 

The best substitutes for human milk are said to be goats' or asses' milk. 
But these can seldom be obtained in this country, and we are obliged, 
therefore, to resort to the milk of the cow. This should never be given 
pure to a child under two months of age. It ought always to be diluted 
with two parts, and if the digestive power be weakened by illness, with 
three, or even more, parts of water. It is very important to determine 
the quantity of food to be given the child in every twenty-four hours. 
From various inquiries and observations that I have made with a view to 
ascertain this point, I have been led to conclude that a healthy infant of 
two or three weeks old, will receive from a good nurse, and digest well, 
about a pint of milk in twenty-four hours. At the end of the first month, 
and in the course of the second, the quantity taken by the child increases 
gradually to about a pint and a half or a quart. 

The data upon which I found these assertions are the following : — A 
woman whom I attended after her confinement, had a pint of milk mea- 
sured, drawn from her breasts daily by the nurse. I asked her how much 
she thought the child, a vigorous, hearty boy, took during the same time. 
Her reply was that, judging from the frequency and vigor with which he 



TREATMENT. 261 

nursed, she was quite sure he took as much as the nurse. I had another 
patient who lost her child in the birth, and who, desiring to go out as a 
wet-nurse, kept up her milk by means of a breast-pump. Six weeks after 
her confinement, I had all the milk she obtained in a period of twenty- 
four hours kept for my examination. It measured just a quart. I made 
very careful inquiries in regard to the point under consideration, of a very 
experienced and intelligent nurse, who has been constantly employed in 
this city for thirty years back. I desired her to answer me accurately 
two questions : 1. How much milk do you think a healthy mother gives 
to her child daily after the flow is fairly established ? 2. What quantity 
of nourishment do you give in twenty-four hours to infants that you are 
compelled to feed exclusively ? The answer to the first was that she had 
often drawn more than a pint from the breasts in the twenty-four hours, 
in addition to what a healthy child took, and that she had frequently 
taken as much as three pints from women who had lost their children. 
She supposed, therefore, that a hearty child would take during the first 
two weeks, at least a pint, and much more afterwards. To the second 
question she replied : that she usually gave to hearty children of one, 
two, and three weeks old, a pint of food in twenty-four hours. 

We may, therefore, I think, assume as a general rule, that a healthy 
child, within the month, ought to take about a pint of nourishment in the 
time specified. 

An infant laboring under thrush would scarcely take so much as this ; 
but if it take only half a pint or a gill in the day, it is clear that it cannot 
be expected to live long on so much less than its natural quantity. It 
ought to take, it seems to me, under these circumstances, about two or 
three table-spoonfuls of food every two or three hours, between morning 
and evening, and once or twice during the night, which would give it from 
eight to ten ounces in the day. The quantity must be regulated, how- 
ever, by the condition of the infant, and particularly by the manner in 
which it takes the food, when offered. The child must never be forced to 
take more than it wants. The moment it seems to have had enough, the 
nurse should cease to offer any more. 

Having determined the quantity, the preparation of the food must be 
attended to. The milk and water ought always to be prepared by boiling 
for two or three minutes, stirring all the time, after which it is to be 
moderately sweetened with white, and not brown sugar. If this is found 
to disagree with the stomach, which is to be inferred when it is always 
rejected by vomiting, and when considerable quantities of undigested curd 
are found in the stools, the diet must be changed. Under these circum- 
stances we may try thin arrow-root or barley water, containing only a sixth 
part of milk ; or cream and water, one part of the former to three, four, 



262 THRUSH. 

or five of the latter; or vre may endeavor to obtain asses' or goats' milk, 
and use it diluted with an equal quantity of water instead t)f two-thirds. 

I would recommend in these cases a diet which I have found to agree 
better with children deprived entirely of the breast, than any other that 
I have ever directed. I have employed it now in a great many instances, 
and believe it to be the best substitute for the natural aliment that I am 
acquainted with. It is made by dissolving a small quantity of prepared 
gelatine or Russian isinglass in water, to which is added milk, cream, and 
a little arrow-root, or any other farinaceous substance that may be pre- 
ferred. The mode of preparation, and the proportions are as follows : a 
scruple of gelatine (or a piece two inches square of the flat cake in which 
it is sold) is soaked for a short time in cold water, and then boiled in half 
a pint of water until it dissolves, — about ten or fifteen minutes. To this 
is added, with constant stirring, and just at the termination of the boiling, 
the milk and arrow-root, the latter being previously mixed into a paste 
with a little cold water. After the addition of the milk and arrow-root, 
and just before the removal from the fire, the cream is poured in, and a 
moderate quantity of loaf sugar added. The proportions of milk, cream, 
and arrow-root, must depend on the age and digestive power of the child. 
For a healthy infant within the month, I usually direct from three to four 
ounces of milk, half an ounce to an ounce of cream, and a teaspoonful of 
arrow-root to a half pint of water. For older children, the quantity of 
milk and cream should be gradually increased to a half or two-thirds milk, 
and from one to two ounces of cream. I seldom increase the quantity of 
gelatine or arrow-root. 

I have given this food to a great many children for about five years 
past, as well to those brought up entirely on hand, as those partly suckled, 
or weaned, and can truly state that they have thriven better upon it than 
upon anything that I have ever employed. In several cases it has agreed 
perfectly well with infants who could not without vomiting, diarrhoea, 
and colic, take plain milk and water, cream and water, any kind of farina- 
ceous food prepared with water, chicken water, or in fact any other food 
that had been tried. In the cases of sick children, it ought sometimes to 
be made even weaker for a while, than in the proportions first mentioned 
above. 

No general treatment is required in the simple idiopathic form of the 
disease, beyond regulation of the diet, and the occasional use of warm 
baths. Local treatment will almost invariably suffice for the cure. 

In the grave form of the disease, it is necessary after regulating the 
diet, to employ remedies for the disordered condition of the alimentary 
canal. These should consist principally of alkalies, astringents, opiates, 
occasionally a dose of some laxative substance, nitrate of silver, and the 



\ 

TREATMENT. 263 

external employment of baths, warm cataplasms to the abdomen, and 
sometimes of revulsives. 

The alkalies usually employed are soda, lime-water, magnesia, chalk, 
and prepared crab's-eyes; of these I prefer in most cases, the soda, lime- 
water, chalk, or crab's-eyes, to be given in the manner which will be re- 
commended in the article on entero-colitis. Dewees recommends very 
highly the following formula : 

R. — Magnes. alb. list., gr. xii. 

Tinct. thebaic, gtt. iii. 

Sacch. alb., q. s. 

Aqurc font., £i. — M. 

A teaspoonful to be given every two hours until the bowels are tranquil. 

He says of it that he has " long adopted it with entire success." In con- 
junction with the internal use of alkalies and astringents, I would recom- 
mend the practice pursued by M. Valleix, of employing opiate enemata 1 
and warm poultices containing laudanum, applied upon the abdomen. 
The enemata should consist of one drop of laudanum in a table-spoonful 
of starch-water, for young infants, to be used morning and evening. The 
poultices may be made of Indian or flaxseed meal, placed between two 
pieces of soft gauze flannel, to be secured around the body by a band, and 
renewed from time to time. 

Purgative remedies are much used in this country in all cases of intes- 
tinal disorder. I believe them to be unnecessary, and generally injurious, 
in thrush, except at the onset, and occasionally through the course of the 
disease, when we may suppose the bowels to contain accumulations of par- 
tially digested aliment, or highly irritating secretions. Under these cir- 
cumstances, and only then, from half a teaspoonful to a teaspoonful of 
castor oil, or a teaspoonful of spiced syrup of rhubarb, containing half a 
drop of laudanum, may be prescribed, and repeated in case the same con- 
dition of things should recur. Once the diarrhoea with green watery 
stools established, I believe all cathartics to be, as a rule, injurious. 

Opiates in moderate quantities, given in combination with alkalies or 
astringents, or used by injection or externally, are of the greatest service 
at all stages of the grave form of the disease. "When the diarrhoea is 
severe and obstinate, and particularly when the stools contain mucus or 
blood, or are attended with tenesmic straining, nitrate of silver given 
internally, and used by injection, may be resorted to with very probable 
benefit. The doses and modes of administration will be described under 
the head of entero-colitis. 

Some authors recomnlend the application of one or two leeches to the 
margin of the anus, or over the left iliac fossa. It seems to me that they 



264 THRUSH. 

can rarely be proper, and if so, only in vigorous, hearty children, and in 
cases presenting strongly marked inflammatory symptoms. When the 
symptoms indicate great exhaustion, or tend towards a state of collapse, 
resort must be had to stimulants, of which the best are weak brandy and 
water, or a mixture of equal parts of wine-whey and arrow-root water. 

Local Treatment. — The local treatment is important in all cases, 
but I am disposed to think that it is of much less consequence than the 
general treatment, and particularly attention to the diet and other hygienic 
conditions of the patient. Topical remedies undoubtedly have the effect, 
however, in many instances, of arresting the progress of the exudation, 
and hastening the resolution of the disease of the mouth ; but I have 
uniformly found in grave cases, that no remedies applied to the mouth 
had any decided influence upon the abdominal disease, which is, after all, 
the cause of the fatal termination in the vast majority of cases. The 
local treatment ought therefore, it seems to me, to be regarded as adju- 
vant only to the general management of the disorder. 

In mild cases the most suitable local treatment, the one recommended 
by Underwood, Dewees, Eberle, and Trousseau and Delpech, and that 
which I have generally employed, is the occasional application to the 
mouth of borax. It may be used mixed with an equal quantity of honey, 
and applied by means of a rag or pencil ; or with an equal quantity or 
two parts of finely-powdered white sugar, of which a pinch is to be put 
upon the tongue every two or three hours; or in solution, in the propor- 
tion of a drachm to two ounces of water. The best mode probably is to 
mix it with honey. If this application fail to arrest the deposit of the 
exudation, we may resort to alum in powder or solution, or better still, 
to solutions of nitrate of silver, or careful cauterization with the solid 
nitrate. The alum may be used in the same manner as borax, or accord- 
ing to the following formula, recommended by M. Valleix : 

R. — Aluminis, gr. xv. 

Mel. rosse, giiss. 

Decoct, hordei, ^"jss. — M. 

In the use of the nitrate of silver, I should resort to a solution of eight 
or ten grains to the ounce of water ; Trousseau and Delpech, however, 
employ one of thirty grains to the half ounce, or more frequently cauterize 
lightly the whole mucous surface with the solid caustic. 

Between the application of any of the above-mentioned remedies, the 
mouth of the infant ought to be occasionally moistened and cleansed with 
some of the mucilaginous solutions, as gum-water, flaxseed tea, or that 
made from sassafras pith, slippery elm bark, or marsh-mallow root. 

Strict and careful attention must be constantly paid to the state of the 



SIMPLE PHARYNGITIS. 265 

skin around the anus, and upon the thighs 'and buttocks. These parts 
ought to be well cleansed after each, evacuation of urine or stool, by 
gentle pressure, and not by rubbing, with a fine sponge dipped into tepid 
milk and water, then dried with a soft napkin in the same manner, and 
well anointed with simple cerate, or what I find better than anything 
else, Goulard's cerate. These precautions ought to be still more carefully 
observed if erythema has already made its appearance. 



CHAPTER II. 

DISEASES OF THE THROAT. 
ARTICLE I. 

SIMPLE OR ERYTHEMATOUS PHARYNGITIS. 

Definition ; Synonymes ; Frequency. — Simple pharyngitis consists 
of an erythematous inflammation of the pharynx, tonsils, and soft palate, 
unaccompanied by ulceration, deposits of false membrane, or gangrene. 
It is not mentioned by Underwood. It is described under the title of 
cynanche tonsillaris by Dewees and Eberle, and of tonsillitis by Stewart 
and Condie. It is very frequent both as an idiopathic and secondary 
disease. I constantly meet with it in children of all ages during the cool 
months of the year. 

Causes. — It may occur at all ages, and is equally common in the two 
sexes. It is more frequently a secondary than an idiopathic affection. 
The diseases in the course of which it is most apt to occur are scarlet 
fever and measles, and next pneumonia and bronchitis. It is often an 
accompaniment of simple laryngitis. The idiopathic form is most common 
in this city in the late winter and early spring months. It is said to 
prevail sometimes in an epidemic form. 

The exciting causes of the disease are not always easily detected. In 
most instances, however, I believe that exposure to cold is the cause of 
the attack. 

Anatomical Lesions. — In mild cases the alterations of texture ob- 
served during life, and in a few instances after death, the patient having 
died of some other disease, consist of greater or less redness, swelling, 
softening, and a rough or granular and sometimes cedematous condition 
of the mucous membrane covering the soft palate, tonsils, and pharynx. 



26G SIMPLE PHARYNGITIS. 






The uvula and tonsils are generally tumefied, and the crypts of the latter 
filled with mucous or purulent fluid of a yellowish colour. In one very 
severe case which proved fatal, MM. Rilliet and Barthez found the tonsils 
very red, soft, only slightly swelled, and infiltrated with pus; the pharynx 
was covered with a thick layer of bloody mucus ; the mucous membrane 
of the throat was of a dark red color, thickened, and granular, but not 
softened. The submaxillary glands were of a grayish color, enlarged and 
soft. 

Symptoms. — Simple pharyngitis of moderate severity begins with 
restlessness, irritability, fever, slight cough, and in some instances, pain 
in the throat, which is complained of by older children, and betrayed in 
those who are very young, by the refusal to nurse or take food, because 
of the difficulty of swallowing. The face is generally flushed, sometimes 
very deeply so. Young children are often drowsy, but from irritability 
and fever refuse to sleep except on the lap. The fever is marked by 
acceleration of the pulse, which rises to 100, 110, or more in children 
over five years of age, and to 120, 130, or 140 in those under that age, 
and by unusual warmth or even heat of the skin. At the same time the 
respiration is generally more frequent than natural, but almost always 
regular ; in cases attended with high fever, I have counted the breathing 
at 42 and 50. Auscultation reveals pure vesicular murmur or slight sibi- 
lant rhonchus. The voice is clear, or, in rather severer cases, obscured 
and nasal, and in some instances, speaking is painful and difficult. Cough 
is a frequent symptom. It was present in 20 of 25 cases observed by 
myself. In 6 of these it was harsh and croupal, so that the children 
seemed threatened with croup. The croupal sound seldom lasted over 
one night, after which the cough was merely hoarse, and gradually became 
loose towards the termination of the attack. In the remaining cases it 
was rare and dry in the beginning, and more frequent and looser as the 
disease progressed. Pain is a frequent, but far from constant symptom 
at the onset of the disease. It generally exists during deglutition. When 
present it is shown in infants, as stated, by their refusing the breast, or 
nursing only at long intervals, and with difiiculty ; while in older chil- 
dren it is complained of. It is not, however, a constant symptom, as I 
have often seen children of one, two, and three years old, with severe 
angina productive of violent fever, who swallowed fluids and soft solids 
without a sign of pain. Of 22 cases in which the state of this symptom 
was particularly noticed by myself, it was present only in 7. Through- 
out the acute period of the disease there is generally considerable thirst; 
the appetite is diminished or entirely suppressed ; the stools are usually 
natural, or there is slight constipation. 

The throat should always be examined when there is the least reason 



SYMPTOMS. 267 

to suspect that an attack of sickness depends upon inflammation of that 
part, and whenever a child has been seized suddenly with fever, particu- 
larly in cold weather, and there is nothing more evident by which to 
explain the illness. To examine this part well, the tongue must be 
strongly depressed with the handle of a spoon, which should be carried 
back to the base of the toDgue. This. may be done in the youngest 
infant. 

The appearances presented by the throat are as follows : — the soft 
palate, uvula, tonsils, and generally the pharynx also, are more or less 
reddened and swelled, and the mucous membrane commonly looks rough 
and granular. The fauces are often filled with frothy mucus, and in 
severe cases, coated all over with mucous or purulent secretions, which 
sometimes line the inflamed surfaces in such a way as to resemble false 
membranes. They are to be distinguished only by careful examination, 
and by removing a small portion on a pencil or sponge mop, in order to 
ascertain their real nature. I have seen the mild form of inflammation 
in a child ten days old, in one eight weeks, another three months, and a 
fourth nine months old. 

The sub-maxillary glands and neighboring cellular tissue are sometimes 
swollen, in consequence of the extension of the inflammation to them. 
This is often evident to the eye, but is more correctly judged of by the 
touch. At the same time the glands arc usually somewhat painful to 
the touch. The amount of swelling is slight in very mild cases, or there 
may be none at all. In severer cases it is much more considerable. 

The breath is said to be often fetid. I .have not met with this charac- 
ter in the simple disease. Expectoration is rarely present. I have never 
noticed it under six years of age. Slight nervous symptoms occur in 
nearly all the cases, consisting, as already stated, of restlessness and 
irritability in mild attacks, and. of insomnia or drowsiness, with starting 
and twitching, in those which are more severe. 

The fever generally occurs at first only in the after part of the day and 
during the night, often becoming intense at that time, with restlessness 
and starting, and subsiding or disappearing entirely towards morning, to 
recur again the next afternoon or evening. Children not unfrequently 
play about all the early part of the day, and are attacked with the symp- 
toms just mentioned, as night comes on. The disease generally pursues 
this course for three or four days, and then passes away entirely, or, if it 
last beyond that time, the fever becomes continued, and the attack runs 
on for seven, eight, or ten days. 

In grave cases of simple angina, the disease begins with vomiting, 
fever, and severe nervous symptoms, in the shape of excessive restlessness, 
or somnolence, and occasionally convulsions. The fever is violent, the 



268 SIMPLE PHARYNGITIS. 

pulse being very frequent and full, and the skin hot and flushed. The 
intense heat and flushing of the skin, which in sanguine children some- 
times affects the greater part of the surface of the body, together with the 
activity of the circulation, not unfrequently make the onset of the disease 
resemble very closely that of scarlet fever. Four cases of this-kind that 
have come under my notice presented severe nervous symptoms at the 
invasion. In a girl between two and three years old, they consisted 
of wildness and ecstatic expression of the face, and trembling uncertain 
movements of the limbs, which would probably have terminated in con- 
vulsions, but for the timely interposition of a warm bath. In the three 
others, general convulsions occurred. Two of the subjects in which 
convulsions took place were between five and six years old, and one 
between three and four. In two the convulsions occurred at the onset, 
and in a third on the second day. The convulsive movements lasted from 
ten to twenty minutes, and were followed by somnolence for a few hours 
in two, and by stupor for a day in the third. It should be stated, how- 
ever, that two of these subjects were predisposed by constitution and 
temperament to spasmodic attacks, as one had had a fit previously from a 
similar cause, and the other two from difficult dentition. The third had 
never suffered from any symptoms of the kind, and did not appear pre- 
disposed to them. 

The tongue is generally dry and coated with a thick whitish fur in 
grave cases; the respiration is quick, loud, and nasal; and the voice 
guttural or nasal, and difficult. There is usually extreme thirst, and 
not unfrequently delirium. The throat is commonly violently inflamed, 
of a deep red color, and coated over with mucous or purulent secretions. 
The sub-maxillary regions are often swelled, and the deglutition some- 
times, though not always, difficult. When the disease proves fatal, the 
different symptoms soon reach their heigh-t, and death may occur in two 
or three days. I have never, however, known simple pharyngitis to 
terminate fatally. The duration of the grave cases is variable. In the 
four that I have met with, it was between three and eight days. 

Secondary pharyngitis, which, as has been stated, is a very frequent 
disease, will be treated of in the articles on the various diseases, in the 
course of which it occurs. 

Diagnosis. — The diagnosis of simple pharyngitis is not always without 
difficulty, as there are no local symptoms in two-thirds of the cases at 
the invasion, nor in some instances at any period of the attack. The 
physician and attendants, therefore, are often deceived as to the real 
cause of the violent fever which has so suddenly made its appearance, and 
are disposed to refer it to any but the true one. 

It has happened to me several times in cases of children attacked with 



TREATMENT. 269 

simple angina, to suspect pneumonia from the sudden occurrence of fever, 
rapid respiration, slight dry cough, and the absence of pain in the throat, 
difficulty of deglutition, or other symptoms to call my attention to the 
real seat of disease. The diagnosis is to be corrected only by the absence 
of the physical signs of pneumonia, and the consequent necessity of 
finding some other cause of the sickness. Angina may be mistaken also 
for indigestion, which is one of the most frequent causes of sudden fever 
in childhood, and is accompanied like severe angina by vomiting. The 
distinction between the two is to be made by careful inquiry as to the 
history of the attack, by examination of the matters ejected from the 
stomach, and by inspection of the throat. Severe cases, particularly when 
ushered in *by convulsions, may be mistaken for disorder of the nervous 
system dependent upon dentition. The only method of ascertaining the 
truth is again the inspection of the throat. Cases of this kind might 
also be mistaken for the beginning of scarlet fever. Time only, and the 
development or absence of the symptoms peculiar to the latter disease, 
could enable us to determine the diagnosis. 

The diagnosis between simple and pseudo-membranous pharyngitis will 
be given under the head of the latter disease. 

Prognosis. — Simple pharyngitis of moderate severity is very rarely, 
if ever, a fatal disease. Severe or grave erythematous pharyngitis, on 
the contrary, is often a dangerous malady. The four cases that have come 
under my care, however, all recovered. The unfavorable symptoms in 
such cases are : very violent fever, greatly altered physiognomy, difficult 
respiration, choked and guttural voice, excessive jactitation, delirium, 
convulsions, and coma. 

Treatment. — Mild cases of simple angina need but little treatment. 
The child ought to be confined to a warm room in all cases, and kept in 
bed, or on the lap, if it have fever. The diet must be restricted to milk 
preparations and bread so long as the fever continues. The therapeutical 
part of the treatment may consist in the use of some mild evacuant, as 
one or two teaspoonfuls of castor oil, half a teaspoonful or a teaspoonful 
of magnesia, a small quantity of syrup of rhubarb, or what is all-sufficient 
in many cases, a simple enema. At the same time we may give, if the 
frequency of pulse, heat of skin, and restlessness be considerable, a few 
doses of sweet spirits of nitre, or spiritus Mindereri, alone, or combined 
with from one to four drops of antimonial wine, according to the age. A 
warm bath, if the child is not afraid of it, is an admirable remedy when 
there is much excitement of the circulation ; or a foot-bath, containing 
salt or mustard may be used. Frictions over the throat and neck are 
often very advantageous ; they may be made with hartshorn and sweet 
oil, with or without the addition of laudanum, or a small quantity of 



•270 



SIMPLE PHARYNGITIS. 



spirits of turpentine may be applied upon the skin, so as to produce slight 
counter-irritation. "When there is much pain and difficulty of deglutition, 
the case is best treated by the use of nitrate of silver in solution (5 or 10 
grains to the ounce), or of powdered alum, applied by means of a large 
throat-brush. 

In the severe form of the disease the treatment must be much more 
active than in mild cases. When the fever is very high, and threatening 
nervous symptoms are present, the most speedy means of controlling them 
is a warm bath, lasting fifteen or twenty minutes. If the effects of this 
should be but slight or transitory, bloodletting must be resorted to. In a 
very young child the proper means of taking blood is by the application 
of a few leeches behind the angles of the jaw; in those who are older, on 
the contrary, a venesection of from two to four ounces is much better, 
because at that age the dread of leeches is so great, that the fright and 
consequent resistance on the part of the child, is always a serious, and in 
some cases an insuperable objection to their use. Some evacuant dose 
should be given early in the attack ; it may consist of castor oil, magnesia, 
epsom salts dissolved in lemonade, fluid extract of senna, or infusion of 
senna and manna. The quantity must be sufficient to produce several 
copious stools, and should it fail to operate in three or four hours, and the 
fever continue, it is always well to assist it by means of a purgative enema. 
Two hours after the exhibition of the cathartic, it will be proper to resort 
to small doses of antimonial wine or tartar emetic solution, with nitre, 
repeated every hour and a half or two hours, in the manner recommended 
in the article on pneumonia. If the secretions into the fauces be very 
abundant and tenacious, so as to impede respiration, the best means of 
getting rid of them is by an emetic of ipecacuanha, hive syrup, or antimo- 
nial wine. If they collect again, the throat ought to be cleansed from time 
time with a small sponge-mop. The inflamed surfaces should be touched 
two or three times a day with a solution of nitrate of silver (from five to 
ten grains to the ounce). My father has been in the habit of employing 
with much benefit in the severe angina of children, whether idiopathic or 
secondary, a wash made according to the following formula : 






-Cupri Sulphat., 
Quiniae Sulphat., 
Aquae Destillatce, 



aa gr. vi. 



This is applied in the same way as the lunar caustic solution, and I have 
frequently seen it produce most excellent effects. 

The four grave cases observed by myself recovered under very simple 
treatment. This consisted in the use of the warm bath ; of doses of castor 
oil to move the bowels freely on the first day, and of syrup of rhubarb or 



PSEUDO-MEMBRANOUS PHARYNGITIS. 271 

enemata afterwards to keep them soluble ; of doses of antimonial wine and 
nitre every two hours in such quantity as to avoid sickness ; of mustard 
pediluvia; stimulating frictions to the outside of the throat; applications 
of lunar caustic solution to the throat internally, three or four times a day ; 
and of rigid diet. In one case the warm bath was used three times in a 
single day, because of the extreme restlessness and heat of skin, and was 
productive each time of great benefit. 



ARTICLE II. 

PSEUDO- MEMBRANOUS PHARYNGITIS. 

Definition ; Synonymes ; Frequency. — Pseudo-membranous pha- 
ryngitis consists in inflammation of the pharynx, accompanied by an exu- 
dation of false membrane upon the mucous tissue. 

It is the disease called by older writers angina maligna or gangrenosa, 
cynanche maligna, etc. In this country it is popularly known by the 
name of putrid sore throat. It is designated angina suffocativa, or sore- 
throat distemper, by Dr. Sam. Bard, of New York, whose paper (Trans. 
Am. Philos. Soc, vol. i.) is the best of the early productions upon the 
subject. It is the diplitlicrite of M. Bretonneau. Underwood and Dewees 
make no mention of it. Eberle, in his chapter on tonsillitis, confounds it 
with simple angina; but it is evident that he had met with the disease 
from the fact of his remarking that flakes of coagulable lymph, resem- 
bling superficial sloughs, sometimes adhere to the inflamed tonsils, and 
that the inflammation passes down into the larynx in some instances. Dr. 
Condie describes it under the title of pseudo-membranous or diphtheritic 
inflammation of the throat. 

It is difficult to arrive at a correct appreciation as to its frequency. It 
may be stated, however, that it is rare as a sporadic affection, while it 
sometimes prevails to a considerable extent as an epidemic disease. 

Causes. — It occurs both in the sporadic and epidemic forms. Guer- 
sant states that it is to be met with in Paris at all seasons, and under all 
temperatures. It is strongly disposed, however, to assume the epidemic 
form, and may then prevail over districts of greater or less extent. 

It has been thought by many to be propagated by direct contagion. 
Such is the clearly expressed opinion of MM. Trousseau (Diet, de Med., 
t. x., p. 393), Valleix (Guide du Med. Prat., t, iv., p. 350), and Guer- 
sant (Diet, de Med., t. iii., p. 128-129). M. Bretonneau (Traite de la 
Diphtherite), is strongly disposed to the same opinion, without, however, 



272 PSEUDO-MEMBRANOUS PHARYNGITIS. 

positively adopting it. Rilliet and Barthez are fully convinced that the 
disease is contagious. I have met with but two instances in my own 
practice which seemed to show that it possessed this character. The first 
was the case of a boy two years and a half old, who was attacked with the 
disease, while his sister, an older child, was already dangerously ill with 
it. The second occurred in a family of three young children, two of whom 
were attacked simultaneously with the disease, which was in both followed 
by fatal croup. The third child remained well for a few days after the 
termination of these cases. It was then attacked. The disease extended 
to the larynx, and the child was saved only by the operation of tracheo- 
tomy. On the other hand, I have met with much more numerous 
instances in which other children were allowed free access to the sickroom, 
and without any extension of the disease. 

Dr. Geddings, of South Carolina, in a valuable monograph on " pseudo- 
membranous inflammation of the throat" (J.m. Jour. Med. Sci. } vol. 
xxiv., p. 82), says that diphtheritis depends on an epidemic constitution 
of the atmosphere, but that " under particular circumstances, as when 
many persons are crowded together, when ventilation is imperfect and 
cleanliness is neglected, there can be no question of the generation of a 
contagious influence, capable of transmitting the disease from one person 
to another." Dr. Bard (Loc. cit.~) y states that the disease was of an 
" infectious nature," and that the infection depended not so tl much on 
any generally prevailing disposition of the air, as upon effluvia received 
from the breath of infected persons. This will account why the disorder 
should go through a whole family, and not affect the next-door neighbor ; 
and hence we learn a very useful lesson, namely, to remove all the young 
children in a family, as soon as any one is taken with the disease ; by 
which caution, I am convinced, many lives have been, and may again be 
preserved." It is said to be most frequent between the ages of 2 and 
8 years, and to be more common in boys than girls. Of 28 cases that 
I have seen, 17 occurred between the ages of 3 and 8 years, to wit, 4 
between 3 and 4 ; 5 between 5 and 6 ; 3 between 6 and 7 ; and 5 between 
7 and 8. Only 2 occurred between 2 and 3 years of age; and 1 between 
1 and 2. Of the 28 cases, 20 occurred in girls, and but 8 in boys. It is 
said that children of feeble constitution, and those subjected to bad 
hygienic conditions or debilitated by severe illness, are particularly 
exposed to it, especially in the sporadic form. 

The secondary form occurs most frequently as a complication first of 
scarlet fever, and then of typhoid fever and measles. 

Anatomical Lesions. — The false membranes covering the pharynx, 
soft palate, and tonsils, are of a yellowish-white or grayish color, of rather 
tough consistence, and of variable thickness. They may consist of one or 



SYMPTOMS — DURATION. 273 

several layers, and adhere with moderate tenacity to the mucous mem- 
brane. They are sometimes ash-colored, and being softened by the pha- 
ryngeal secretions and tinged with blood, which latter is often exuded 
from the mucous tissue in diphtheritic inflammation, they have, under 
these circumstances, been frequently mistaken for sloughs of the mucous 
membrane, thus giving rise to the old titles of angina gangrenosa, putrid 
sore throat, etc. The mucous membrane is generally injected and red, 
and often presents ecchymosed spots. In some cases it is softened and 
roughened, or even deeply ulcerated, so that the false membrane may rest 
upon the muscular tissue of the pharynx. The ulcerations, though rare in 
the primary, are not uncommon in the secondary form. The submaxil- 
lary glands are almost always enlarged, but very seldom in a state of sup- 
puration. 

In the secondary form of the disease, the mucous membrane is more 
violently inflamed. It is of a deep red color, rough, and very much thick- 
ened and softened. The tonsils are large and soft, uneven, and often 
infiltrated with pus. It is not unusual in this form, to meet with ulcera- 
tions of the mucous membrane. False membranes are almost always 
present ; generally on different portions of the fauces, and more rarely over 
their whole extent. They are generally rather soft and thin, of a whitish, 
grayish, or yellow color, dispersed in fragments, and easily torn. The 
inflamed parts are usually bathed in purulent fluid. The submaxillary 
glands are large, red, and soft. 

Symptoms; Duration. — The disease begins usually, but not in all 
cases, with slight fever. The strength and appetite are not much dis- 
turbed at first, but, as the attack progresses, the former is diminished and 
the latter suppressed ; the thirst remains natural. There is at the same 
time, in some, but not all cases, pain in the throat, which may or may not 
be accompanied by difficulty of deglutition. Both these symptoms are, 
however, often very slight, or they may be entirely wanting, a fact with 
which the practitioner ought to be well acquainted, as the absence of local 
symptoms by which to explain the cause of the sickness, gives to the 
disease, in some instances, an insidious character which may well mislead. 
In one fatal case at three years of age that came under my notice, there 
were neither complaints of pain, nor difficulty of swallowing, so that the 
parents had not the least suspicion of the throat being the seat of disease, 
though I found it violently inflamed, and covered with deposits of thick 
false membrane in points. On another occasion I was sent for to see two 
children who had been sick for four days with slight fever, languor, and 
loss of appetite, but who were not thought to be seriously ill. I found 
them both laboring under extensive membranous angina, which proved 
fatal a few days later by the induction of croup. I attended a few years 

18 



274 PSEUDO-MEMBRANOUS PHARYNGITIS. 

since, for three days in succession, a boy who was attacked suddenly with 
vomiting and slight fever, loss of appetite and languor, and whom I sup- 
posed to be suffering from mere gastric irritation. His only local symptom 
was pain in the chin, and this was not reported to me until afterwards. 
The mother chanced to look into his throat, and finding there some whitish 
spots, sent me word. I found him with very considerable membranous 
exudation, which was fortunately prevented from extending into the 
larynx by proper treatment. Twice, lately, have I been sent for to see 
children attacked with croup, and, on finding the fauces thickly covered 
with exudation, have been told that the patient had been ailing for near a 
week before with languor, slight peevishness, loss of appetite, and some 
little pain in the throat. The symptoms, prior to the development of the 
croup, had been so mild in bo'th cases as to cause no alarm, and yet the 
anginose disease had evidently been progressing insidiously for several days. 

If the throat be examined on the first day of fever, the exudation may 
often be found even at that time, though it is sometimes not formed before 
the second day. The fauces generally present slight swelling and redness 
before the appearance of the false membrane, which almost always shows 
itself first on one of the tonsils only, in the form of whitish or opaline 
spots, like coagulated mucus, which soon run together and extend over 
the whole gland, and then to the soft palate and pharynx, though it some- 
times remains limited to the tonsils and soft palate. A little later in the 
attack the plastic deposit exists in the form of layers of greater or less 
extent ; it has lost its transparency, become firmer in consistence, thicker, 
and changed from a white to a yellowish-white or lardaceous and some- 
times grayish color. The submaxillary glands are almost always enlarged 
and slightly painful to the touch about three or four days after the appear- 
ance of the pseudo-membrane. The breath is offensive but not fetid. 
When this form of the disease, which is the one most frequently observed, 
is left to pursue its natural course, the pseudo-membrane becomes thinner, 
assumes a grayish tint, and falls off about the sixth or seventh day. When 
on the contrary, topical remedies are applied to the throat, the membrane 
is often detached after one, two, or three days, but may be reproduced 
several times before the conclusion of the case. 

In another and more violent form of the disease, the pseudo-membrane, 
about the time that it begins to be detached, assumes a grayish or blackish 
color, and hangs in shreds from the surfaces to which it was attached. 
The fauces, under these circumstances, present a gangrenous aspect, the 
mucous membrane having an appearance as though it were falling off in 
sloughs; the breath is extremely fetid, and there is more or less abundant 
salivation, or in some cases an expuition of sanguinolent fluid. There can 



SYMPTOMS. 275 

be no doubt that it was from misconception of such cases as these, that the 
titles of gangrenous and putrid sore throat arose. 

As the exudation disappears from the pharynx, the swelling of the 
parts affected gradually subsides. The mucous membrane, from which 
the plastic deposit has just fallen, is more or less injected and red; the 
tonsils and soft palate are sometimes found to be reduced below their 
natural size. 

The general symptoms of pseudo-membranous pharyngitis are often 
slight, as has already been stated in a preceding paragraph, compared with 
the dangerous character of the local affection. There is generally but 
little fever, attended with very moderate heat of skin during the first few 
days, after which it often increases and the skin becomes hot and dry, 
though, not unfrequently, these symptoms are but slightly marked 
throughout the attack. When, on the contrary, the fever is more violent 
during the first day or two, it usually subsides soon, though in some 
instances it remains intense, and in one of the cases observed by myself, 
the pulse was full and frequent and the heat very great after the second 
day. The principal symptoms connected with the digestive organs are loss 
of appetite and moderate thirst. These are not generally present in the 
beginning, but make their appearance a few days after the invasion. 
Vomiting is rare and the stools are normal. 

The voice is commonly obscured and nasal, but not hoarse nor whisper- 
ing unless the disease extend into the larynx, in which case the symptoms 
will be those of true croup as already described. Cough sometimes exists, 
but it usually resembles in sound that produced by the action of hawking 
rather than a common cough, and is altogether different from the tone of 
the cough of laryngitis. 

The only other symptoms which require mention are the presence of 
more or less marked languor, depression, and loss of strength. 

The pharyngeal inflammation and exudation frequently exhibit a strong 
tendency to extend to the larynx, and it is this which usually causes the 
fatal termination. At other times they spread to the nasal passages, and 
thereby add greatly to the danger of the case. Again, the false mem- 
branes are formed in some rare cases upon different portions of the general 
integument, particularly upon the alse nasi, behind the ears, about the 
anus, vulva and nipples, and upon a blistered or any excoriated surface. 

The duration of the disease, independent of complications, is usually 
about seven, eight, or nine days. If it extend into the air-passages very 
soon after the invasion, it may cause death within a few days. In most of 
the cases, however, the larynx does not become implicated under five or 
six days. In one of my cases death occurred on the fourth day, in one on 
the fifth, in one on the sixth, in one on the seventh, and in one on the 



276 PSEUDO-MEMBRANOUS PHARYNGITIS. 

eighth. In all but one the fatal termination was caused by the extension 
of the exudation to the larynx. In the exceptional case it was caused by 
the malignancy of the attack, and by enormous swelling of the glands and 
of all the tissues about the lower jaw and under the throat. Bard says 
that of seven deaths, five occurred before the fifth, and two about the 
eighth day. 

Diagnosis. — It has already been stated that this disease sometimes 
begins with but faintly-marked local symptoms, and with general symp- 
toms of so mild a character, as to allow it to run on to a dangerous extent, 
before the attendants of the child became at all alarmed in regard to the 
condition of the patient, and without their suspecting even, in one instance, 
the true seat of the disorder. The diagnosis can present no difficulties to 
the physician, if only he examine the throat, but it is possible that, 
when there are no complaints of pain in throat, and no marked difficulty 
in swallowing, his attention may be directed, as happened to myself, towards 
some other part of the body ; he may neglect to look into the fauces, and 
the disease may thus pass unperceived for the first few days. The pre- 
sence of any swelling of the lymphatic glands under the jaw, embarrassed 
movements of the neck, and the absence of other causes to explain the sick- 
ness of the child, ought, however, always to lead to an inspection of the 
fauces, and this would, in an instant, reveal the true character of the attack. 

The distinction between simple and pseudo-membranous angina can only 
be made out during the existence of the pharyngeal exudation, as the 
symptoms of the latter disease are nearly identical with those of the former, 
before the deposit and after the fall of the false membranes. 

Prognosis. — If the disease remains limited to the pharynx, it is almost 
always a very curable affection. When, on the contrary, it extends to the 
nasal passages, the prognosis is more unfavorable, and when the larynx 
becomes implicated, the prognosis is exceedingly grave ; if the disposition 
to the production of false membrane spread to the skin, rectum, or vulva, 
the prognosis is also very grave, and death generally occurs in a state of 
profound adynamia. Of 28 cases that I have seen, 5 proved fatal. In 4 
of the 5, death was caused by the extension of the disease into the larynx, 
and the consequent production of croup. In the other case, the fatal 
event occurred early, and apparently from the great malignancy of the 
attack, and from enormous swelling about the jaw and neck. In 5 other 
cases, the exudation also implicated the larynx, and caused severe croup, 
but they all recovered. In 9 cases therefore, of the 28 ; croup followed the 
anginose disease, and of these 4 died. 

Treatment. — The treatment may be usefully considered under two 
heads, the local and general. It is now generally supposed that the former 
is more important than the latter, though, for my own part, I am con- 



TREATMENT. 277 

vinced that they are of nearly equal consequence. The great object to 
be held in view, is to prevent, if possible, the extension of the pseudo- 
membrane from the fauces into the larynx and nasal passages. 

Local treatment. — The most important of the local remedies are the 
nitrate of silver and muriatic acid. These are the two remedies most 
highly recommended by MM. Bretonneau, Valleix, Grisolle, and Killiet 
and Barthez. Dr. Geddings (Joe. cit.) speaks very highly of the success 
of the caustic treatment in his hands, in the epidemic which occurred in 
Charleston during 1837 and 1838. He employed either the nitrate of 
silver or muriatic acid. 

The nitrate of silver is employed in solution or substance. The latter 
form is objected to by many on account of the risk of its slipping from the 
port-caustic into the pharynx, and thence passing into the stomach. The 
solution is therefore generally preferred. Bretonneau employs it in the 
proportion of half an ounce of the nitrate to an ounce and a half of water. 
The strength of the solution is very different as recommended by different 
authorities, some proposing a saturated one, and others one of from a 
drachm to ten grains of the salt to the ounce of water. I have usually 
made use myself of one of twenty grains to the ounce, and have found it 
abundantly strong for my purposes. It may be applied either by means 
of a piece of sponge fastened upon a proper handle, which is the best 
method, or a camel's hair pencil, nearly as large as the end of the little 
finger. The application should be made once, twice, or even three times, 
in the course of the twenty-four hours. Dr. Geddings recommends, when it 
is desirable to use the solid nitrate, to reduce it to powder, and to roll the 
sponge probang previously moistened with mucilage of gum arabic and 
squeezed in the powder, until a sufficient quantity adheres, and to apply it 
thus prepared to the diseased parts. 

The muriatic acid is employed by M. Bretonneau either pure or mixed 
with honey. When the limits of the pseudo-membrane can be seen in the 
pharynx, he uses the concentrated acid, and carrying the sponge, after it 
has been dipped into the acid, and squeezed so as to be merely moistened, 
rapidly into the pharynx, he cauterizes lightly and withdraws it. When, 
on the contrary, the limits of the membrane cannot be seen, he dilutes 
the acid with an equal quantity of honey, and leaving more of it on the 
sponge than in the previous case, he recommends that the latter be passed 
down over the glottis, and then pressed against the base of the tongue, by 
raising strongly the handle to which it is tied, in order to express a few 
drops upon the mucous lining of the larynx. The cauterization is to be 
performed once or twice a day according to the necessity of the case. For 
children under ten years of age, the sponge ought to be about half as 
large as a pigeon's egg. The sponge is to be fastened to a piece of flexi- 



278 PSEUDO-MEMBRANOUS PHARYNGITIS. 

ble whalebone, by making a crucial incision into it, introducing into this 
the end of the whalebone, and securing it with good sealing-wax, which is 
not acted upon by the acid as any ligature would be. When about to be 
used the whalebone is warmed and curved into such a shape as will allow 
it to pass into the pharynx without touching the roof of the mouth. M. 
Valleix proposes that the sponge should be fastened to the whalebone 
with waxed thread, and this to be covered with sealing-wax, to preserve 
it from the action of the acid. This would certainly be safer than the 
mere wax itself. 

Applications of powdered alum and chloride of lime are recommended 
by writers of high authority. In slight cases, in which the disease shows 
but little disposition to extend, such applications may answer very well, 
but when the attack is threatening, and especially when the exudation is 
spreading, we should neglect all minor remedies of this kind, and resort 
at once either to lunar caustic or muriatic acid. If, however, the powders 
are employed, they may be applied by means of a throat-brush, or by causing 
a sufficient quantity to adhere to the forefinger of the right hand, and con- 
veying it upon this to the diseased surfaces. 

There is no real difficulty in making use of any of these applications, 
if the children be properly managed. One or two assistants must hold 
the patient in such a way that the head shall be thrown backwards, and 
the hands and feet secured. The physician must depress the tongue with 
the handle of a spoon held in the left hand, while he holds in the right 
the pencil or sponge-mop. If the child refuse to open the mouth, it can 
generally be made to do so by holding the nose in order to force it to 
breathe through the mouth. If this fail, all that is necessary is to press 
the handle of the spoon against the teeth, when the patient will soon be- 
come too much fatigued to offer further resistance. 

General Treatment. — Bloodletting may be resorted to with advan- 
tage very early in the attack, if the child is vigorous and strong, the fever 
violent, and if there are no signs of prostration. When, on the contrary, 
the case is not seen within the first two or three days, depletion can seldom 
be resorted to with safety. By some it is proscribed entirely in the treat- 
ment of the disease. Thus M. Valleix {Loc. cit. t. iv, p. 369) says : 
" I will merely state that there is not a single case on record in which the 
disease was evidently arrested by antiphlogistic treatment, however ener- 
getic it may have been." I believe, however, that I once saw the disease 
arrested by depletion. During the last week of October, 1845, my father 
and myself were in attendance upon a girl five years of age, laboring under 
a most violent attack of the disease, which had extended into the larynx 
and which, for several days exposed her life to the most imminent hazard. 
During the extremity of her illness, her brother, a fine hearty boy two 



TREATMENT. 279 

years and a half old, was taken sick in the evening of one day with con- 
siderable fever. On the following day, my father found the fauces very 
much inflamed, while at the same time there were patches of pseudo-mem- 
brane on each tonsil, and high febrile reaction. The boy was bled at once 
to four ounces. Four grains of calomel were given, and a few hours after- 
wards a dose of purgative medicine. The throat was touched with a so- 
lution of nitrate of silver, of ten grains to the ounce. The exudation was 
arrested at this point, though the fever continued for two days longer. It 
may be said that the nitrate of silver arrested the disease, but the solution 
was not a caustic one, and therefore hardly likely, it seems to me, to have 
produced, by itself, so powerful an effect. I am disposed to believe from 
my own experience in this and other cases, that when resorted to early, 
and in vigorous subjects, it is a highly important and powerful remedy. 
I have employed it, on the contrary, later in the disease, without any 
good effects, and should, under such circumstances, depend rather on the 
local treatment, and the employment of mercurials. 

Mercury. — The preparations of mercury are undoubtedly those which 
are most powerful in causing the dissolution and absorption of the pseudo- 
membrane. But, as Rilliet and Barthez remark, so long as the disease 
remains confined to the pharynx, there is but little danger attendant upon 
it, and it would be unnecessary, therefore, to resort to so powerful an agent 
as mercury in such cases. We can ascertain with some degree of certainty 
whether the inflammation is likely to extend into the larynx or not, by 
learning whether the disease be sporadic or epidemic, and if epidemic, 
whether it has shown a disposition to pass down into the air-passages. If 
it be a sporadic case, or if the epidemic has not in general attacked the 
larynx, we may rely upon the local treatment, and bloodletting as advised 
above. If, on the contrary, the disease be epidemic, and if it has shown a 
disposition to propagation into the larynx, the case should be treated with 
mercury, as this remedy has seemed to exert a more powerful influence in 
arresting the formation of the deposit than any that has been resorted to. 
The preparation generally made use of is calomel, which may be given in 
the dose of a grain every two hours, until the disease appears to yield, or 
until some of the effects of the remedy on the constitution are visible. It 
is better in general to combine a small portion of opium with it, in order 
to prevent too early an action upon the bowels. 

Of late years I have found that any remedy that reduces the febrile 
condition of the system, is of use in diminishing the local disease. Anti- 
mony has proved very efficient for this purpose in my hands, either in the 
form of antimonial wine, of which two or three drops mixed with ten drops 
of sweet spirits of nitre, may be given every two hours, in that of tartar 
emetic in the dose of the twentieth or thirtieth of a grain, or, what I 



280 PSEUDO- MEMBRANOUS PHARYNGITIS. 

usually prefer, the golden sulphuret of antimony, in combination with 
Dover's powder and calomel. From half a grain to a grain of calomel, a 
twelfth or twenty-fourth part of a grain of the antimony, with a quarter or 
half a grain of Dover's powder, given every two hours, to children of five 
or six years old, will almost always reduce the pulse, produce free perspi- 
ration, and greatly assist to prevent the extension and cause the removal 
of the local disease. 

Eme'ics. — Purgatives. — Emetics are useful when the exudation 
shows a disposition to extend to the larynx, or when there is much diffi- 
culty of breathing from tumefaction of the fauces, or from accumulations 
of the pseudo-membranous deposits. I would recommend under these 
circumstances the use of alum in the manner proposed in the article on 
pseudo-membranous laryngitis. If this be not employed, ipecacuanha or 
tartar emetic ought to be resorted to. The emetic may be repeated in six 
or twelve hours, if the same indication should continue or recur. A pur- 
gative dose is useful at the commencement of the disease as an antiphlo- 
gistic and evacuant. After that period, only such laxatives need to be em- 
ployed as may suffice to keep the bowels soluble. 

Tonics and Stimulants are to be resorted to only in the gangrenous 
form of the disease, or towards the termination of the ordinary form, if 
the patient become weak and prostrated. In the grangrenous form the 
tonic treatment should be combined with the local treatment already de- 
scribed. Under these circumstances, the diet ought to consist of nutritious 
milk preparations, and of light broths, while wine and brandy in the form 
of whey, or milk punch, may be given in connexion with quinine, or some 
of the preparations of bark. 



CHAPTER III. 

DISEASES OF THE STOMACH AND INTESTINES. — GENERAL REMARKS. 

The diseases of the digestive tube are involved in so much obscurity 
in consequence of the various forms in which they present themselves, 
and of the different opinions held by authors as to their nature, that I 
find myself greatly perplexed as to what may be the most proper manner 
in which to treat of them. After careful consideration, however, I have 
resolved to divide them into two classes, one of which will include all that 



DISEASES OP THE STOMACH AND INTESTINES. 281 

seem to depend on simple functional derangement, independent of any 
anatomical alteration, cognizable by our senses ; and the other those which 
depend on evident inflammation or its consequences. It seems to me 
that this division is shown to be correct, by the following considerations : 
1. I believe that I have often met with cases of derangement of the 
digestive tube which could not be explained as to their causes, symptoms, 
course, and mode of recovery, on the supposition of inflammation or other 
appreciable anatomical alteration. 2. There are on record a considerable 
number of cases of greater or less derangement of the functional expres- 
sion of these organs, in which the most careful examination after death 
could detect no alteration in the tissues to explain the symptoms. Such 
are the cases referred to by Billard, who says (Mai. des Enfans, p. 392) : 
" Many children at the breast have diarrhoea without enteritis ; they lose 
color, become etiolated, fall into a state of marasmus, but at the autopsy 
not a trace of inflammation of the intestines is found." Berton (Mai. des 
En/ants, 2me ed., p. 574) states that of 57 cases of gastro-intestinal 
disease observed by himself, there were 4 in which not a trace of inflam- 
mation nor any appreciable lesion of the digestive tube could be found. 
MM. Eilliet and Barthez (t. i, p. 491) remark that in about every twelve 
children affected with more or less abundant diarrhoea, in whom we might 
expect to find colitis, there will be one in whom the gastro-intestinal tube 
will be found in a state of perfect integrity. They add that this conclu- 
sion is deduced from a comparison of nearly three hundred autopsies. 
3. It is the opinion of several competent observers that such a division of 
the diseases of the digestive tube ought to be made. Billard treats of 
stomachal and intestinal indigestion, which, he says, may exist indepen- 
dently of inflammation. Barrier (Trait. Prat, des Mai. del* Enfance) is of 
opinion that it is indispensable to distinguish certain lesions of secretion, 
which he describes under the title of diacrises (a word first employed by 
M. Gendrin), from the inflammations of the gastro-intestinal tube. He 
asserts (t. iv, p. 19), that gastro-enteritis, gastritis, and enteritis, rarely 
constitute in children from one to fifteen years of age, complete and 
essential morbid conditions, conditions, that is to say, governed in their 
manifestation, course, duration, termination, and treatment, by the same 
laws which preside over other essentially inflammatory diseases. In 
proof of this, he states that in 122 cases of disease of the abdomen 
observed by himself, there were 54 of diarrhoea, 10 only of inflammatory 
or catarrhal gastro-intestinal disease, 2 of verminous affection, and one of 
ulceration of the duodenum. Of these 67 cases, he says that five-sixths 
at least of the attacks of diarrhoea ought to be classed anion o-st the dia- 
crises or lesions of secretion. After describing the alterations which 
occur in the follicular diacrisis, he says (loc. cit. p. 33) : " These altera- 



28! 



DISEASES OF THE STOMACH AND INTESTINES. 



tions are evidently not of an inflammatory nature, and do not therefore 
justify us in giving to the disease the title of gastro-enteritis, or colitis, as 
has been done by most of the later writers, and particularly Billard, who 
attributed them to follicular gastritis or enteritis." M. Barrier accord- 
ingly describes, first, the inflammatory affections of the digestive tube, 
under the usual title of gastro-intestinal inflammation; and then the 
diacrises or lesions of secretion of the gastro-intestinal mucous mem- 
brane. Of the latter class he makes five divisions : 1, follicular or 
mucous diacrisis; 2, acescent diacrisis; 3, serous diacrisis; 4, ventose 
diacrisis; 5, verminous diacrisis. M. Bouchut (Man. Prat, des Mai. 
des Nbuv-Nes) divides the diarrhoeas of children into catarrhal or spas- 
modic, and inflammatory diarrhoea or entero-colitis. The former disease 
he believes to depend on a functional lesion with hyper-secretion of the 
intestinal mucous membrane, the anatomical cause of which escapes our 
search. It is independent, he says, of any appreciable alteration of the 
digestive tube. 

I think it must be admitted, from the facts and opinions just stated, 
that there are two distinct morbid conditions of the digestive tube ; one, 
in which there are no evident anatomical lesions, and another which 
depends upon inflammation and its results. To the first of these condi- 
tions I will apply, when it affects the stomach, the term indigestion ; and 
when it affects the intestines, that of simple diarrhoea. To the second 
class I shall apply the usual terms, gastritis, enteritis, and colitis. I 
would remark, however, that it seems most probable that these two states 
are often merely different degrees of disease, and that simple functional 
derangement will very often become inflammation, if it continue for any 
length of time. The follicular or mucous diacrisis of MM. G-endrin and 
Barrier, probably depends at first upon functional disorder of the secre- 
tory apparatus of the digestive tube, which frequently passes into inflam- 
mation and its consequences. 

Before beginning the history of the diseases of the stomach and bowels, 
I would call the attention of the reader to the well-established fact that it 
is much more common to meet in children with affections of these two 
portions of the alimentary canal existing simultaneously, than with 
affections of either alone. Of 150 cases of inflammation of the infra- 
diaphragmatic portion of the digestive tube, carefully collected by Billard, 
there were 90 of gastro- enteritis, 50 of enteritis without gastritis, and 
only 10 of gastritis without enteritis. Of 57 cases of gastro-intestinal 
affections observed by M. Berton (loc. cit., p. 574), there were only 4 of 
gastritis alone, whilst there were 27 of gastritis complicated with some 
intestinal lesion, 4 of enteritis, 11 of entero-colitis, and 4 of colitis. In 



INDIGESTION. 283 

3 there was merely slight development of the isolated follicles, and in the 
remaining 4 not a trace of inflammation nor any other lesion. 3IM. 
Rilliet and Barthez state that they have met with 61 cases attended with 
some lesion of the stomach, in only 15 of which was that organ alone 
affected, whilst in the remaining 46 there was either duodenitis, enteritis, 
colitis, follicular enteritis or colitis, or lastly, softening of the mucous 
membrane. The authors of the Bibliotheque du Medecin Praticien state 
(t. v, p. 573), "that it is rare to find any serious alteration of one of its 
(gastro-intestinal canal) portions, without the others participating to a 
greater or less extent." M. Bouchut (loc. cit.) appears to think that 
diseases of the stomach never occur in children as a separate lesion, at 
least he asserts this of softening of that organ (p. 231), and treats of the 
other alterations of its mucous tissue only under the head of entero-colitis. 



SECTION I. 



FUNCTIONAL DISEASES OF THE STOMACH AND INTESTINES. 



ARTICLE I. 



INDIGESTION. 



Definition; Frequency; Forms. — By the term indigestion, I mean 
that condition of the stomach in which its function of digestion is dis- 
turbed or suspended, independent of inflammation or other disease of the 
orga*n, appreciable by our senses. It is a very frequent affection during 
the whole period of childhood, and is one of great importance on this 
account, and from the fact of its laying the constitution open by the 
debility and cachexia which it produces, to various secondary affections. 
In my description of the disease, I shall distinguish between the forms 
which occur during infancy, and after the completion of the first 
dentition. 

Causes. — The principal causes of indigestion in infants are an un- 
healthy state of the milk of the nurse, the use of artificial diet, and 
lastly, an impaired condition of the digestive function, which disables the 
stomach from digesting even the most healthful aliment. 

The milk of the nurse may be too old for the child, for it has been found 
that a breast several months old, sometimes, though not always, disagrees 
with a young infant, in consequence no doubt of the milk being thicker 



284 INDIGESTION. 

and richer at that time than immediately after parturition. The breast- 
glands may continue to secrete colostrum for weeks or even months after 
parturition, and when this is the case the child is almost sure to suffer 
from indigestion and diarrhoea. The milk may be unwholesome because 
the nurse is in bad health, or because her diet is not properly regulated. 
That the diet of the nurse affects her milk, I have no doubt, though this 
has been denied by some persons. 

I have known several children to suffer from indigestion, attended with 
vomiting, acid secretions, colic, and diarrhoea, in consequence of the nurse 
having indulged in a very rich diet, and particularly in vegetables and 
fruits. I do not mean to assert that all nursing women should abstain 
from fruits, or even live on a very simple diet, for I have known some 
who could make use of the richest food, and eat abundantly of all kinds 
of vegetables and fruits, without the least injury to their milk. But there 
are others who cannot do so without occasioning indigestion in their 
infants, either because their milk -glands extract something hurtful from 
such food, or because their children are unusually susceptible to the action 
of the materials absorbed from that kind of food. Again, it is clearly 
proved, it seems to me, by recorded cases, and by the opinions of various 
authorities, that the milk of the nurse is affected by her moral condition. 
Children have been known to suffer greatly, and even to die from 
taking the milk of a nurse who had just before undergone a fit of violent 
anger. The depressing moral emotions, as anxiety, grief, fear, and 
despair, are well known to affect the milk secretion, in such a way as 
sometimes to occasion indigestion. 

The use of artificial diet for young infants, or as the expression is, 
" bringing up on hand or the bottle," is, I believe, by far the most fre- 
quent cause of indigestion during infancy. Very many children with 
whom this is attempted die of indigestions, chronic diarrhoeas, gastritis, 
entero-colitis, and thrush. Very few escape frequent attacks of one or other 
of the diseases just named. Much depends, no doubt, on the selection and 
preparation of the food. It may be stated as a well-established fact, that 
a diet consisting wholly or in great part of farinaceous substances, very 
rarely fails to disagree with the child, and to produce indigestion and 
other disorders of the digestive system which often prove fatal ; while one 
in which cow's or goat's milk enters as the principal ingredient, though in- 
ferior to the natural aliment, and often productive of indigestion, is far 
less injurious than the one before spoken of. 

A third cause of indigestion was stated to be the absence or loss of the 
digestive power of the stomach, independent of the nature of the food. 
This is a condition similar to the dyspepsia of the adult. It may be con- 
genital or may result from causes brought into action after birth. It often 



SYMPTOMS. 285 

remains as a consequence of previous indigestions from improper or exces- 
sive feeding. It exists during the invasion, course, and convalescence of 
various diseases. Dentition frequently diminishes or impairs the tone of 
the digestive function, so that the child is often unable, during that pro- 
cess, to digest aliment which had agreed with it perfectly well at other 
times. 

The causes of indigestion after the completion of the first dentition are 
congenital feebleness of the digestive function ; the want of power of that 
function, which remains often for years in children reared upon artificial 
diet, and in those who have been debilitated by frequent attacks of disease 
of any kind ; the habitual use of improper diet ; the eating of crude, indi- 
gestible food ; the process of the second dentition j the want of due exer- 
cise in the open air ; residence in large cities ; and undue exercise of the 
mental faculties in the conduct of the education of the child. 

Symptoms. — I shall describe first the symptoms of indigestion as it 
occurs during infancy, and secondly as it occurs during childhood, or after 
the completion of the first dentition. 

Indigestion during infancy may be advantageously considered under two 
heads : as occasional or accidental, and as habitual. By the former I 
mean that which occurs in a healthy infant from a transient cause, such as 
repletion or a momentarily unhealthy state of the nurse's milk from some 
imprudence on her part as to diet, from some moral cause, or from sickness ; 
and that which depends upon the passing influence of dentition. By 
habitual indigestion, I mean the form of the affection which is long con- 
tinued in consequence of a persistence of the cause. 

The symptoms of occasional or accidental indigestion in infants are : 
paleness and contraction of the face; restlessness and peevishness; moan- 
ing and crying, or in some cases, screaming ; nausea, shown by excessive 
paleness, often by very great languor, and by occasional retching, which 
may either subside without vomiting, or as more frequently happens, ter- 
minate in that act; flatulent distension and hardness of the abdomen, 
especially in the epigastric region, often accompanied with eructations ; 
and in many of the cases simple diarrhoea. These symptoms usually come 
on soon after nursing freely, or after a very hearty meal of artificial food, 
in a child previously in good health. The attack seldom lasts more than a 
few hours or one or two days. The vomiting which almost always takes 
place, and which relieves the stomach from the offending cause, very often 
accomplishes the cure. 

Habitual indigestion in infants causes a train of symptoms which are 
different from, and much more severe than those just described. Of these 
the most important are : frequent attacks of nausea and vomiting, and of 
simple diarrhoea repeated for days, weeks, or months in succession ; pale- 



286 INDIGESTION. 

ness, or some other unhealthy tint of the cutaneous surface; continual 
restlessness and discomfort, with fretting or crying, particularly in the 
after part of the day and during the evening and night, in place of the 
natural ease and quiet of a healthy infant; constant fits of the most violent 
screaming from colic, sometimes lasting for hours; dull and languid 
expression of the countenance, or else an uneasy, contracted look, like that 
produced by continued suffering ; more or less emaciation ; failure of the 
natural growth in stature and size, so that the child is small and puny for 
its age; want of calorific power, causing the child to suffer unusually from 
cold, as shown by frequent coolness of the hands and feet ; irregular appe- 
tite, which requires to be tempted by frequent changes of the food, or 
more or less complete anorexia; and lastly, the various symptoms that 
indicate an impoverished state of the blood and bad nutrition. 

In some cases there are added to the above symptoms, those of gastritis 
or entero-colitis, to be hereafter described. Indigestion probably seldom 
proves fatal in infants, except from the occurrence of some inflammatory 
complication, as for instance, one of the diseases just named, or acute dis- 
ease of some other principal organ. 

Indigestion in children who have completed the first dentition may, as 
in the case of infants, be occasional or habitual. Occasional indigestion 
occurs in strong and vigorous, as well as in more delicate subjects. The 
attack generally begins within a few hours or a day after the child has 
eaten some indigestible substance, with languor and chilliness in older 
children, and with languor and peevishness in those who are younger ; 
after which there is headache, pain in the stomach in most of the cases, 
and very often a disposition to somnolence. If the child is attacked with 
vomiting soon after the appearance of these symptoms, and ejects the of- 
fending material, it will often seem perfectly well from that time. If, how- 
ever, this do not take place, fever, sometimes of a violent character, is 
almost certain to make its appearance. The pulse becomes very frequent, 
rising to 120, 130, or even higher, and being full and resisting; the skin 
becomes flushed, dry, and very hot; the appearance of the tongue is not 
generally changed early in the attack ; there is considerable thirst ; the 
child is restless and uneasy, tossing from side to side, or it lies in an 
uneasy sleep, attended with frequent starting and jerking of the limbs or 
crying out ; the abdomen is natural, or hard and distended over the epi- 
gastric region. When the symptoms just described make their appear- 
ance suddenly, by which I mean in the course of a few hours, in a child 
two, three, four, or five years old, after it has eaten some indigestible sub- 
stance, there is reason to fear an attack of convulsions. The probability 
of the occurrence of this accident is great in proportion to the earliness 
of the child's age, and the impressibility of its nervous system. The at* 



SYMPTOMS. 287 

tack is particularly to be apprehended, and should be carefully guarded 
against, whenever the fever is violent, when there are urgent complaints 
of headache, when the restlessness and agitation are very great, or when 
there is somnolence, with frequent startings or twitchings of the muscles. 
Convulsions sometimes occur without any previous warning, or after such 
slight signs of disorder as would fail to produce uneasiness in the parents 
or attendants. 

The symptoms produced by occasional indigestion generally continue 
until nature relieves the stomach by vomitiog or diarrhoea, or until the 
remedies proper in the case, the most important of which are evacuants, 
have been administered. It happens not unfrequently, that symptoms of 
gastric or intestinal disorder remain for some days after the violence of 
the attack has subsided, and in some instances the disturbance is so great 
as to occasion gastritis, entero-colitis, or dysentery. 

Habitual indigestion in children who have completed the first dentition, 
is not at all an uncommon affection. It is a condition analogous to, if not 
identical with, the dyspepsia of the adult. The symptoms of this form are 
the following. The general appearance of the child is delicate, as shown 
by a pallid or sallow tint of the skin, instead of the ruddy complexion of 
health, by thinness and want of proper development of the limbs and 
trunk, and by softness and flaccidity of the muscular tissues. There is an 
habitual air of languor and listlessness, with absence of the usual gaiety 
and disposition to play natural to the age, and the child often complains 
of being tired. The appetite is feeble or uncertain, being sometimes absent, 
and at other times too great ; or it is peculiar, there being a willingness 
to eat of dainties, but a refusal of food of a simple character. The tongue 
presents nothing peculiar. It is however more frequently somewhat furred 
than clean and natural. The temper is usually irritable and uncertain. 
The child rarely sleeps well; on the contrary, the nights are restless and 
much disturbed, the sleep being broken and interrupted by turning and 
rolling, by moaning or crying out, and by grinding of the teeth. These 
latter symptoms, together with picking at the nose, which is a frequent 
accompaniment, are almost always referred by the parents and nurses to 
worms, and it is often impossible to convince them to the contrary, even 
though frequent and violent doses of vermifuges have failed to show the 
existence of entozoa. The state of the bowels is uncertain. In some 
instances they are very much constipated, requiring frequent doses of 
laxatives, or careful regulation of the diet, to keep them soluble ; in others 
they are inclined to be loose, and when this happens, the stools are often 
lienteric. In others, again, constipation and diarrhoea alternate. The 
abdomen is usually natural, or somewhat enlarged from flatulent disten- 
sion; complaints of pain are not uncommon. This form of indigestion, 



288 INDIGESTION. 

like dyspepsia in the adult, is generally a very chronic affection, seldom 
lasting less than several weeks or months, and sometimes for years. 

Diagnosis. — The occasional indigestion of infants is not likely to be 
mistaken for any other complaint. The suddenness of the attack, the 
character and quantity of the matters ejected from the stomach, the absence 
of symptoms indicating the invasion of any other disorder, the short dura- 
tion of the symptoms, and the rapid recovery, all render the true nature 
of the case very clear. That which occurs in older children, on the con- 
trary, is not so easy of diagnosis. In many cases the invasion is not unlike 
that of scarlet fever. The vomiting and frequency of the pulse, the great 
heat of the skin, and in some cases a certain suffusion of the integument 
dependent on the activity of the circulation, all render the case doubtful 
for some hours, or for a day, after which time the difficulty ceases, from 
the development of the symptoms peculiar to the disorder. I believe 
that not a few cases of simple angina are mistaken for indigestion, owing 
to the absence of complaints of sore throat, and the neglect of the physician 
to examine that part. In such cases the vomiting and sudden attack of 
fever are ascribed, for the want of another mode of explaining them, to 
gastric derangement. The diagnosis can be maole only by examination of 
the fauces. The diagnosis of indigestion accompanied by convulsions will 
be considered in the article on the latter affection. 

The habitual indigestion of infants is not likely to be confounded with 
any other disease. The absence of fever, of tenderness of the abdomen on 
pressure, or other acute symptoms, all indicate the dependence of the dis- 
order on functional distress of the stomach. The same remarks apply to 
this form of the disease occurring in older children. Nevertheless, the 
practitioner should never neglect to make a careful examination, both of 
the physical and rational signs, of all the important organs of the body, as 
it sometimes happens that latent disease of some one of them is the cause 
of the gastric difficulty. 

Prognosis. — The prognosis of occasional indigestion is nearly always 
favorable. It is rarely a dangerous disorder, unless accompanied by con- 
vulsions, or some other signs of violent disturbance of the nervous system. 
Under the latter circumstances, the prognosis should be very cautious, as 
the termination is not unfrequently fatal in consequence of injury done to 
the nervous centres. It should be recollected also that this form of indi- 
gestion sometimes becomes the exciting cause of inflammation of the 
stomach or intestines, in which event the prognosis will be that of those 
diseases. 

Habitual indigestion in infants is a serious complaint, and ought always 
to awaken the solicitude both of the physician and parents ; for though a 
simple functional disease of the stomach is not probably often fatal, it is 



TREATMENT. 289 

exceedingly apt to prove so by the induction of gastritis, chronic enteritis, 
colitis, or thrush, or by its laying the system open to other diseases, and 
rendering it less able to withstand them, should they happen to occur. In 
older children it is not, according to my experience, so dangerous a malady. 
I have never as yet seen it terminate fatally. 

Treatment. — The treatment of occasional indigestion in infants ought 
to be very simple. The child has generally relieved itself by vomiting 
before the physician is called. If, however, it continues pale and languid, 
with vomiting or retching, after the stomach seems to have been emptied, 
the proper plan is to make use of remedies to calm the irritability of the 
organ. This can almost always be accomplished by giving a teaspoonful 
every ten or fifteen minutes, of a mixture of lime-water and milk, consist- 
ing of one-third milk to two-thirds lime-water, or of equal proportions of 
each. At the same time a small mustard plaster, weakened with wheat 
flour, may be applied to the epigastrum, or a warm indian mush poultice 
in a flannel bag, laid over the whole abdomen. Should these means fail 
to relieve the sickness, from half a drop to a drop of laudanum, or ten 
drops of paregoric may be administered, and repeated if necessary in two 
hours. The child generally recovers its usual health after the sickness 
has entirely ceased. If, however, it remain fretful and uneasy, if it cry 
much as though in pain, it is probable that a portion of aliment has passed, 
in a partially or wholly undigested state, into the intestine. The suspicion 
will be confirmed if the abdomen is found upon palpation and percussion 
to be swelled, hard, and resonant from flatulent collections in the bowels. 
Under these circumstances, a laxative ought to be given. The best dose 
is half a teaspoonful or a teaspoonful of castor oil, a teaspoonful of simple 
or spiced syrup of rhubarb, or, if there have been evidences of an acid 
state of the stomach, about a quarter of a teaspoonful of the best mag- 
nesia. 

The occasional indigestion of older children demands a different and 
more energetic treatment. After ascertaining that the child has eaten 
something indigestible, we should inquire whether there has been vomiting. 
If there has been none, or if only slight, it will be proper to give an emetic 
immediately. The best one under the circumstances is ipecacuanha. 
This rarely fails to produce a full effect, and does not perturbate the sys- 
tem, or irritate the stomach like tartar emetic. It may be given either 
in powder or syrup. The dose is familiar to every one. If the ipecacu- 
anha be not at hand, we may use hive syrup, which is kept in almost every 
house, or a teaspoonful of powered alum in honey or molasses, to be re- 
peated, if necessary, in fifteen minutes. Alum is less apt to fail than 
either ipecacuanha or hive syrup. If the child continue unwell after the 
operation of the emetic, which is often the case, and particularly if the 

19 



290 INDIGESTION. 

fever be considerable, a purgative should be given as soon as the stomach 
will bear it. The best dose is castor oil, which is the most speedy and 
least irritating. It may be given in orange juice, which forms an excel- 
lent vehicle, or, if the child is old enough, in the froth of beer or porter. 
A dessert-spoonful is generally enough. If the oil cannot be taken, we 
may give infusion of senna and manna, the fluid extract of senna mixed 
with spiced syrup of rhubarb, syrup of rhubarb alone, magnesia, to be fol- 
lowed by lemonade, salts and magnesia, or the former alone, or lastly a 
seidlitz powder. If the fever continue, and the cathartic fail to operate in 
four or six hours, a purgative enema ought to be given to hasten its effect. 
A bath at about 96° or 97° will almost always be found useful in these 
cases. The child should be kept in the bath from eight to twelve or fif- 
teen minutes. The only circumstances which form an objection to this 
remedy are the facts of the patient being so irritable, or so fearful of the 
water, as to make it necessary to contend with him in order to succeed in 
using it. When this is the case it had better not be employed, and spong- 
ing with tepid water and spirit should be substituted. If the child com- 
plains of pain in the stomach, the application of a warm mush poultice 
over the epigastrium or whole abdomen will be found of much service. 

When, in this form of indigestion, the febrile reaction is violent, as it 
often is, and particularly when there are signs of great disturbance of the 
nervous system, consisting of excessive agitation, complaints of severe 
headache, drowsiness, moaning or crying out in the sleep, or twitching 
and jerking of the muscles, the physician should beware of a convulsive 
attack. In such cases as these the patient ought to take a purgative dose 
of calomel (from three to four grains), have a warm bath at once, soon 
after an injection, and if not considerably relieved in a very few hours, 
be bled at the arm to three or six ounces. The remedies ought to be 
prompt and energetic, for the case is pressing. A convulsion is always a 
dangerous event in childhood, and should be prevented, if possible. About 
two hours after the calomel has been given, a cathartic dose had better be 
administered, in order to insure an action upon the bowels, and to carry 
the calomel out of the system. These means rarely fail to afford relief 
in a few hours. The diet should be absolute during the violent stage of 
the attack, and the usual diet is to be resumed only by degrees. The 
drinks may be plain water or gum-water taken cold. 

It not unfrequently happens that occasional indigestion is followed by 
gastritis or enteritis, or by habitual indigestion lasting, for weeks or even 
months. These different sequelae must be treated according to the plan 
proper for each. 

The habitual indigestion of both infants and older children requires a 
very different treatment from the occasional or accidental form. In both 



TREATMENT. 291 

the indications are nearly the same. The most important are very careful 
regulation of the diet in all its details, the use of tonics and stimulants 
to restore tone and vigor to the digestive function, the employment of 
remedies to correct the state of the bowels, whether they be relaxed or 
constipated, and attention to securing the child proper exercise, exposure 
to the air, and suitable clothing. 

If the symptoms of the disorder occur in a child at the breast, the 
milk of the nurse should be carefully examined, in order to ascertain 
whether it be good. If found to possess any unhealthy qualities, the 
nurse ought to be changed at once. Attention to this point alone will 
almost certainly cure the child. It needs no other remedy. 

If the patient is fed wholly or in part, it is essential to regulate the 
diet to suit the state of the digestive function. Milk ought in all cases 
to form the basis of the food, unless it has been found by patient trial to 
be absolutely repugnant to the stomach. I have often found that infants 
who had been thought quite incapable of digesting cow's milk, could do 
so very readily when it was very much weakened with water. The usual 
proportions for an infant of a few months old, are half and half, or two 
parts milk for one of water. When these are found to disagree, it is well 
to try three, or even four or five parts of water to one of milk, and if the 
stomach digest this, as it often will, the proportion of milk may be slowly 
and cautiously increased to the usual standard. If we conclude that milk 
cannot be digested by the child, it is best to try cream. Of this, one 
part to three or four of water, may be given. When neither of these can 
be taken, some of the farinaceous substances may be tried ; arrow-root, 
sago, barley, tapioca, oatmeal, or rice. I am clearly of opinion, however, 
that these articles prepared with water alone, rarely agree with children 
when they are continued for any considerable length of time. Some 
infants of six or eight months old, it may be remarked, who cannot digest 
more than very small quantities of milk, will take and digest well, very 
delicate broths made of chicken or mutton, or small quantities of the 
lightest meats, as mutton, chicken, or very tender beef, minced up ex- 
tremely fine, and given by teaspoonfuls. 

In cases of this kind I have found a diet consisting of gelatine, 
milk, cream, and arrow-root, prepared in the manner directed in the 
article on thrush (see p. 262), to suit better than anything else. I have 
met with several children, and with two in particular, whom it was 
necessary to feed to the amount of a pint or a pint and a half a day, in 
addition to their being nursed occasionally, who could take neither milk and 
water, cream and water, milk and arrow-root, oatmeal gruel, rice gruel, 
nor indeed anything that was tried, without vomiting, colic, and severe 
diarrhoea, who digested perfectly well and throve admirably upon the 



202 INDIGESTION. 

preparation alluded to. I have now used it during several years, and 
have recommended it for a great many children, and do not hesitate to 
say that it agrees with a larger number than any other diet I have ever 
employed or seen employed. 

The diet of older children laboring under chronic weakness of the 
digestive function is as important as that of infants. Two chief ends 
should always be borne in mind in selecting it, digestibility and nutri- 
tiousness. The former is all-important, for without it, the stomach, con- 
stantly irritated by improper food, has no chance of regaining its tone, 
while the latter is necessary in order to sustain the strength of the child, 
and allow it to carry on its growth. I have generally found it most 
prudent, and often really necessary, to specify as to the substances to be 
given at each meal. The morning and evening meal ought to consist of 
bread and milk, mush and milk, or of milk, warm water and sugar (called 
in this country children's or cambric tea), and bread and butter, and 
nothing else in most of the cases. It is sometimes proper to allow a soft- 
boiled egg, particularly if the child be very fond of it. The dinner ought 
to consist of light broths containing rice, with bread or toast, or of the 
plain meats, as mutton, beef, chicken, turkey, birds, or fine game. No 
vegetable ought to be allowed in most of the cases except rice, as all 
others, even the potato, are very apt to disagree. I believe that the 
potato is more digestible when roasted than when boiled. If the child 
require anything between breakfast and dinner, it may have what is allowed 
at breakfast, or dry bread and nothing else. There are various articles of 
diet which should be absolutely forbidden, amongst which are hot and sweet 
cakes, and hot bread of all kinds ; sausages, not unfrequently given to 
children in this country j corn-beef, ham, veal, pork, goose, ducks, fish ; 
all manner of dessert, excepting rice-pudding, or curds-and-whey, often 
called junket; sweetmeats, candies, fruits, except some of our finest sum- 
mer ones ) and to conclude, everything which long observation and expe- 
rience have shown to be unsuitable for a dyspeptic stomach. 

It is sometimes very difficult to find anything to agree well with the 
child. In one case of a child three years old that came under my ob- 
servation, neither milk, bread, nor meat, could be taken. The caseum of 
milk seemed to be absolutely indigestible, as it would be rejected from 
the stomach many hours, or even a day or two after the milk had been 
taken, in the form of masses of dry, fibrous cheese, of an oblong shape, 
nearly or quite as large as a peach-stone. After trying various articles 
I found that the child digested raw oysters, soda-biscuit, and rennet- 
whey, and upon these articles alone she lived for two weeks, at the end 
of which time she had improved so much as to be able to take the white 



TREATMENT. 



293 



meat of chicken very finely minced. She gradually regained her previous 
health. 

After regulating the diet, such remedies as tend to invigorate the 
digestive functions ought to be prescribed. The most important of these 
are the vegetable and mineral tonics, and mild stimulants. I have found 
quinine, iron, and small quantities of port wine or brandy, to succeed 
better than anything else. To a child under two years old, from a quarter 
to half a grain of quinine, and to one over that age, a grain, may be given 
three times a day, and continued for two, three, or four weeks. It is 
best given to young children diffused, without being dissolved, in a 
mixture of equal parts of syrup of gum and ginger ; while to those who 
are older it may be administered in pill. The best preparations of iron 
are the iodide, or the pure metallic iron prepared with hydrogen. Of 
the former, half a drop to one drop for infants, and from one to two drops 
for older children, may be given three times a day ; of the latter a quarter 
of a grain for infants, and half a grain to a grain for those who are above 
that age, may be given three times a day. The metallic iron is best 
administered in pill or suspended in syrup of gum arabic. When there 
is any suspicion of a scrofulous taint in the child's constitution, or when 
it is disposed to have chronic irritations, excoriations, or ulcerations of 
the nostrils, or papulae or pustules about the eyelids or other parts of the 
body, it is useful to give the iron in compound syrup of sarsaparilla, of 
which half a teaspoonful three times a day is quite enough. Under these 
circumstances, and particularly when the dyspeptic condition is accom- 
panied with frequent nausea or occasional vomiting, with frontal headache, 
and with constipation, seeming to indicate a disposition to tubercular 
deposit in the system, I have found cod-liver oil the most efficient of all 
the remedies that I have tried. It has often removed with great rapidity 
the dyspeptic symptoms, invigorated the general health, and, in fact, 
restored the patient to health. The dose is from half a teaspoonful to a 
teaspoonful twice or three times a day, at the age of six or eight years. 
It is best taken in a small quantity of malt liquor, or floating on strong 
mint-water or syrup of ginger. In very young children, and in older 
ones also, when the latter refuse to take it in the ordinary methods, the 
following formula for its administration will be found one of the best : 



R.— 01. Jec. Aselli, . 
P. G. Acaciae, 
01. Cinnamomi, . 
Sacch. Alb., . . 
Aq. Cinnamomi, . 
Ft. Mistura. 
Dose — A dessert-spoonful three times a day, — after eating. 



§ss. 
gtt. vi. 
^iii. — M. 



294 SIMPLE DIARRHCEA. 

In connexion with these remedies, a little port wine or brandy, and the 
former is preferable in children over a few years old, on account of the 
possibility of their contracting a taste for the brandy, may be allowed 
twice or three times a day, or at dinner only. To young children one or 
two teaspoonfuls of brandy may be given in the course of the day, mixed 
in water ; of the port wine from a teaspoonful to a tablespoonful, accord- 
ing to the age and strengh of the patient, may be repeated morning, noon, 
and night. 

If the bowels are inclined to constipation, they should be kept soluble 
by laxative enemata, and by the use of rhubarb or aloes ; when relaxed, 
the frequency of the discharges may be controlled by the cretaceous mix- 
ture, by anodyne enemata given once or twice a day, by the aromatic 
syrup of galls (to be described under the head of entero-colitis), or by 
some of the astringents in common use. 

In all cases of chronic indigestion in children, it ought to be regarded 
as an essential part of the treatment to secure to the patient a proper 
amount of exercise in the open air. In summer the child should pass 
several hours of every day in the air. It ought, indeed, if the heat of 
the sun can be avoided by proper shade, to pass the whole day in this 
way. In winter it is, of course, impossible to carry this system to the 
same extent, but the child should nevertheless be taken out at least once 
a day ; this may be done in the coldest, and even in damp weather, if 
sufficient clothing be worn. If a child comes back from a walk with warm 
limbs, and with its cheeks in a glow, there is little danger of cold. The 
quantity of clothing must depend on the constitution and idiosyncrasy of 
the patient. Some need twice as much as others. The proper amount 
is best determined by the temperature and coloration of the surface after 
a walk. 



ARTICLE II. 



SIMPLE DIARRHCEA. 



General Remarks. — I have already said that I should treat of two 
different morbid conditions of the intestinal tube, one in which there is 
no evident anatomical lesions to explain the symptoms, and which appears 
to depend on simple functional derangement, to be designated by the title 
of simple diarrhoea; and another in which there is evident inflammation 
with its results, to be described under the titles of entero-colitis and 
cholera infantum. The reasons for adopting this division have already 






GENERAL REMARKS — CAUSES. 295 

been given in the general remarks upon the diseases of the stomach and 
intestines, and it is unnecessary to repeat them at this place. 

Dewees, Eberle, and other writers treat of the diseases of the intestines 
under two heads only, those of diarrhoea and cholera infantum. Stewart 
and Condie treat of the same diseases, but describe inflammation of the 
intestines also, by the titles of enteritis and colitis. Most of these writers 
make different forms of diarrhoea, the feculent, bilious, mucous, chylous, 
and lienteric, and it would seem most natural that I should follow the same 
plan. I am disposed to believe, however, that these varieties ought not to 
be regarded as constituting separate and essential morbid conditions of the 
intestinal tube, but that they are, on the contrary, merely degrees or 
stages of simple diarrhoea or functional derangment, and of entero-colitis 
or inflammation of the intestines. We may in fact have feculent, bilious, 
mucous, -or lienteric discharges at different stages of both these diseased 
conditions. It seems to me most proper therefore not to consider them 
as distinct affections, though I shall continue to employ the terms, in 
order to express the characters of the diarrhoea in different diseases of the 
intestinal tube. I would remark in further elucidation of this point, 
that the feculent diarrhoea of the above authors, comes as a general rule 
within the class of simple diarrhoea, whilst in other instances it is merely 
one of the symptoms of the first stage of entero-colitis; and that the 
bilious, mucous, and lienteric diarrhoea may exist both in the functional 
and inflammatory diseases of the bowels. 

Definition \ Frequency: — By simple diarrhoea, I mean the form of 
diarrhoea which exists without perceptible signs of inflammatory action 
in the intestine ; which is known by post mortem examinations to occur 
without appreciable anatomical lesions ; and which we must conclude, 
therefore, to depend on simple functional derangement. 

It is undoubtedly a very frequent ailment in children, more especially 
from birth to the termination of the first dentition. It is of common, 
though of less frequent occurrence, from the last-mentioned period to the 
age of eight or ten years, after which, according to my experience, it 
becomes rare. 

Causes. — The causes of the disease during infancy are unfavorable 
hygienic conditions, as the habitation of unwholesome, ill- ventilated, 
damp, and filthy dwellings, or of contracted and crowded quarters of 
cities and towns; an unhealthy state of the milk of the nurse; the use of 
artificial diet at too early an age, especially when badly chosen ; cold ; 
dentition; and lastly, great atmospheric heats. The most important of 
these are improper alimentation, by which I mean the use of artificial diet, 
and particularly one consisting chiefly of farinaceous substances to the 
exclusion of a proper amount of milk, and dentition. For a fuller account 



296 SIMPLE DIARRHCEA. 

of the influence of these different circumstances on the digestive organs 
of children, the reader is referred to the remarks on the causes of entero- 
colitis. 

The chief causes of the disease after the first dentition are, according 
to my experience : the habitual use of improper food ; the loss of diges- 
tive power, which often follows a severe indigestion, or an attack of some 
acute disease; the debility of constitution which attends sudden and rapid 
growth; the leant of proper exercise and exposure to the air; the pre- 
disposition which exists in some children from hereditary causes; and the 
disturbing influence of the second dentition. 

The system of indiscriminate diet allowed to children in this country 
is, it seems to me, a fruitful cause of gastric and intestinal complaints. 
I believe that, as a general rule, children over two and three years of 
age, are allowed amongst us to eat of the food prepared for the older 
members of the family. Xow, any one who will reflect upon the variety 
of dishes habitually placed upon an American table, ought not to be 
surprised to see children permitted a choice amidst such profusion, pale, 
thin, delicate, exposed to frequent indigestions, attacks of diarrhcea and 
entero-colitis, to gastric fevers, and the host of minor ills attendant upon 
feeble digestive powers. I am acquainted with some families in this 
city, the children of which, from the age of two years, are allowed habitu- 
ally to breakfast upon hot rolls and butter, hot buckwheat cakes, hot 
Indian cakes vulgarly called dabs, rice-cakes, sausages, salt fish, ham or 
dried beef, and coffee or tea ; to dine upon a choice of various meats and 
a great variety of vegetables, which latter they often prefer to the exclu- 
sion of meat, and then to make a rich dessert of pies, puddings, preserves, 
or fruits ; and lastly to make an evening meal of tea and bread and butter 
almost always relished, as the term is, with preserves, stewed fruits, hot 
cakes of some kind, or with radishes, cucumbers, or some similar dish. 
Add to such meals as the above the eating between whiles of all kinds of 
candies and comfits, which children here regularly expect in larger or 
smaller quantity, cakes both rich and plain, fruits to excess and at all 
hours from soon after breakfast to just before going to bed, raisins and 
almonds, and nuts of various kinds, and the wonder is, not that we are a 
pale, thin, dyspeptic, and anxious-looking race of people, compared with 
Europeans, but that we have any health at all, when our children are 
allowed to make use of the indiscriminate and unwholesome diet just 
described. Such a system undoubtedly occasions frequent attacks of the 
disease under consideration, and unless the diet be changed early in the 
attack, it is very apt to become chronic. It has been stated that simple 
diarrhoea sometimes followed as a consequence of indigestion. I have 
known such a result to occur in children previously in fine health, and to 



SYMPTOMS. 297 

continue for several weeks or months. In these instances, the disorder 
appears to depend in good measure on the loss of the digestive power of 
the stomach. This seems proved by the great influence which the cha- 
racter of the food has upon the malady, which is always aggravated by 
the use of any articles except those universally acknowledged to be the 
most digestible, and also by the frequent coexistence of lientery when the 
food is not of the lightest kind. 

I have several times met with cases which I could ascribe to no other 
cause than debility and want of power of the digestive organs, dependent 
upon too rapid growth. That sudden and rapid growth may produce 
feeble digestion, or in other words, a dyspeptic state, is, in my opinion, 
proved by the following consideration. It is attended with loss of appe- 
tite, emaciation, paleness, languor, and weakness, and frequent attacks of 
diarrhcea, or a chronic form of that disorder; all of which symptoms are 
greatly influenced by the regimen of the child, and are most readily 
removed by attention to that point, and by the use of tonics and stimu- 
lants. 

The other causes enumerated need but little comment. I will merely 
remark that I have several times observed a predisposition to weakness of 
the digestive organs, transmitted apparently from parent to child. As to 
the influence of the second dentition, I have no doubt that it is a frequent 
cause of the complaint, and I believe that it is too little attended to by 
practitioners. 

Symptoms. — I shall describe first the symptoms of simple diarrhcea in 
infants, and afterwards those which characterize the disorder in older 
children. In infants the appearance of the diarrhoea is usually preceded 
or accompanied by slight disturbance of the temper and comfort of the 
child. There is some degree of restlessness, 'peevishness, and disposition to 
cry ; the child sleeps less than usual, and often starts and moans during 
sleep; all of which symptoms are more marked, as is the case indeed in 
nearly all the ailments of children, during the night. Though the symp- 
toms described are observed from time to time, and particularly during 
the night, they are not always present, as the infant will occasionally 
through the day seem perfectly well and comfortable, with the exception 
perhaps of slight paleness and languor, almost always perceptible upon 
its countenance. There is no fever in these cases, or at least nothing 
more than unusual warmth of the hands, feet, and abdomen, at night. If 
a marked febrile reaction take place, there would be reason to suspect the 
existence of some degree of entero-colitis. The mouth often becomes, 
after a few days, a little warmer and less moist than usual ; the tongue is 
generally moist and only slightly coated ; and the appetite is commonly 
diminished, as shown by the child's nursing with less eagerness and at 



298 SIMPLE DIARRH(EA. 

longer intervals than before. In very mild cases the stools are at first, 
and sometimes throughout the attack, feculent : the only differences 
from their ordinary characters are that they are more frequent, thinner, 
more copious than usual, and that the odor is changed so as to become 
acrid and offensive. In severe cases, they contain less feculent matter, 
become yet more fluid and sometimes watery, and exhibit small particles 
of a greenish color, scattered through them ; or the whole of the dis- 
charge is of a deep green color, and it is intermixed with portions of 
mucus. In many of the cases, whitish lumps, evidently consisting of 
undigested curd, are observed mixed with the other substances upon the 
napkin. The number of stools varies from two, three, or four, to six or 
eight, in the twenty-four hours. The number last mentioned is seldom 
exceeded, so long as the diarrhoea remains simple. The abdomen is 
seldom distended, or painful to the touch. The general appearance of 
the child almost always shows the effects of the malady upon the consti- 
tution, after a few days. The countenance becomes paler and thinner; 
the eyes look somewhat hollow j the edges of the orbits are more defined, 
and often present a pale bluish circle ; slight emaciation takes place, and 
the flesh of the child becomes softer and more relaxed than before the 
attack. The duration of the disorder is generally short, as it seldom 
lasts more than three or four days, or a week. It may terminate in com- 
plete restoration to health, without its having exposed the life of the 
child to danger, or, if the causes which gave rise to it continue in action, 
if the child is of delicate constitution or the treatment not correct, and 
especially if this is of too perturbating a character, it is very apt to run into 
entero-colitis and expose the patient to all the dangers of that disease. 

In older children (after the first dentition), the disease is much less 
frequent than in infants, and presents a different train of symptoms. 
Often it is nothing more than a slight disorder of the bowels, amounting to 
three, four, or five stools, thinner and more abundant than usual, accom- 
panied by slight colicky pains, and unattended by fever or other signs of 
sickness, which, after continuing for one, two, or three days, ceases, and 
the child regains its usual health. Some children are particularly liable 
to these attacks, and suffer from them every few weeks, or after any 
indiscretion in diet ; whilst in others they are rare, let the diet be what it 
may. 

There is another form of simple diarrhoea, however, of which I have 
seen nine cases, much more troublesome than the one just described. It 
occurs in children from two and a half to seven and eight years of age, 
lasts a considerably longer time, and is much less under the control of re- 
medial measures. This form of the disease has never in the cases that I 
have seen, been accompanied by fever, or by any constitutional symptoms 



SYMPTOMS — DIAGNOSIS — PROGNOSIS. 299 

rendering it necessary to confine the child either to the bed or house. The 
only symptoms besides the diarrhoea which I have observed, have been 
some degree of paleness, and moderate emaciation : slight weakness, shown 
by an indisposition on the part of the child to play with its usual spirit, by 
an inclination to lie about from time to time through the day on the sofa 
or floor, and by complaints of "being tired;" irritability of temper and 
peevishness ; irregular appetite ; picking of the nose ; and restless, dis- 
turbed sleep at night, attended with moaning, crying, starting, and 
grinding of the teeth; all of which symptoms generally convince the 
mother that the child is suffering from worms. The abdomen is some- 
times slightly tumid, but remains natural as to tension, and is not painful 
on pressure. There is no pain except slight colics in some cases. The 
stools have generally numbered from three to five, and in a few cases as 
many as six or eight a day. They are semi-fluid in consistence, often of 
a very offensive odor, and consist usually of feculent matter, which is 
sometimes clay-colored, more frequently dark brown, and, in other 
instances, deep yellow or orange in color. They are often also of a frothy 
character. In two of the nine cases that I have seen, there was lientery 
whenever the aliment was otherwise than of the lightest and most diges- 
tible kind. In all, the diarrhoea was evidently greatly influenced by the 
diet, showing, it appeared to me, a manifest dependence of the malady 
upon the condition of the stomach, which seemed to have lost in a greater 
or less degree its digestive power. 

The course of the disease in this form was variable. In some it would 
last a few weeks, and then, under the influence of diet and remedies, 
cease, to recur and run the same course after a short period. In others it 
has lasted a much longer time in spite of all treatment that I attempted. 
In three of the cases it continued between three and four months, with 
occasional slight remissions, brought about apparently by remedies which 
a day or two after would seem to lose their effect. In two others it 
lasted about two months ; in another six weeks ; in another a month ; in 
the remaining two cases the exact duration is not recollected. 

Diagnosis. — The diagnosis of simple diarrhoea will rarely present any 
difficulties, since there is nothing with which it could be confounded, 
except the diarrhoea from tubercular ulceration of the bowels, or entero- 
colitis. From the former it is to be distinguished by the history of the 
case, and by the signs of tuberculization in other parts of the economy ; 
from the latter by the absence of signs of inflammatory action. 

Prognosis. — The prognosis is favorable so long as the disease remains 
simple. The physician should never forget, however, the disposition 
which is inherent in it to pass into entero-colitis, nor fail to make the pos- 
sible occurrence of this transition one element in his prognosis. During 



300 SIMPLE DIARRHffiA. 

infancy it is always more serious than after that period, from the feebler 
power of resistance on the part of the constitution to disease at that age, 
which undoubtedly allows this simple affection to prove fatal in some in- 
stances, probably from the shock to the nervous system. After infancy it 
is rarely a dangerous disorder, both because of the greater stamina exist- 
ing at that age, and from the fact that the disposition to extension of dis- 
ease is less strong. 

Treatment. — The prophylactic management of simple diarrhoea is the 
same as that which is proper for entero-colitis, and as that affection will 
be treated of at considerable length in a future article, I must on account 
of my limited space, refer the reader there for information on this point. 

After the disease is established the treatment must consist first in 
attention to the diet, exercise, and state of the gums of the child. In 
many cases, careful regulation of the diet and exercise, and lancing the 
gums when they are much distended and vascular from the pressure of 
the advancing teeth, will suffice to arrest the disorder in a few days, 
without the necessity of resorting to drugs, which ought certainly to be 
avoided whenever it is possible to do so. If the child is at the breast, 
we must ascertain whether the milk of the nurse is good, by inquiry as 
to its appearance, by examination with the microscope, and by reference 
to her health, diet, temper, &c, all of which circumstances more or less 
affect the mammary secretion. If we conclude that the milk is good, or 
that it has been disturbed in its healthy properties only by a transient 
cause, the child must be continued at the breast, with the precaution, 
however, of not allowing it to nurse quite as much as usual. An infant 
suffering from any kind of diarrhoea, had better be restricted entirely to 
the breast, unless it be clear that the supply of milk is quite insufficient. 
If we determine that the milk is unhealthy, the nurse must either be 
changed, or the child weaned ; of course the former alternative is infinitely 
preferable if the child is under a year old, or even eighteen months, if it 
seem to have a rather delicate constitution. 

If the case occur in a child already weaned, or in one fed partly on 
artificial diet, the regulation of the kind, preparation, and quantity of 
aliment is of the utmost consequence. It ought to consist chiefly of milk 
or cream weakened with water, unless it has been clearly shown by pre- 
vious trial that these articles do not agree with the child. I prefer before 
any kind of diet that I have ever employed, or known to be employed, 
that made from cow's milk, cream, arrow-root, and gelatine, in the manner 
described at page 262. The proportions of the milk, cream, and arrow- 
root must vary with the age and digestive power of the patient. I will 
merely state, as a general principle, that during the existence of diarrhoea, 
or at least the early stage of it, and before the strength has been reduced 



TREATMENT. 301 

by the disorder, the proportions of cream and milk ought to be conside- 
rably less than in health. Not only this, but the total quantity of food 
in the day should be diminished, unless the ordinary amount seems to be 
really necessary for the sustentation of the strength. If it be found, 
however, after patient trial, that the child either will not take, or does 
not digest this kind of food, we may try arrow-root or rice-water, thin 
gruel or panada, alternated with very carefully prepared chicken or mutton 
water. If the child is six or eight months old, it often suits well to 
allow it a piece of juicy beef or a chicken bone to suck, or from one to 
several teaspoonfuls of meat of chicken or mutton minced very fine. 

For older children with a common attack of simple diarrhoea, the diet 
should consist for a few days of boiled milk with bread, of gruels made 
with boiled milk and arrow-root, of rice-flour, sago, tapioca, or common 
wheat flour, and of small quantities of light broths. Meats are, for the 
time, improper, and all vegetables, with the exception of rice, yet worse. 

In the cases of infants it is best to recommend a continuation of the 
ordinary exercise, unless the weather be cold and damp. Indeed, in 
good weather, exposure to the air and proper insolation are more impor- 
tant during the existence of this disorder than even during health. The 
same remarks apply to older children, with the exception that they ought 
not to be allowed to fatigue themselves, particularly in warm weather, as 
this would have a tendency to aggravate the complaint. 

When the disorder occurs in a teething child, the gums ought always 
to be examined by the physician, and if found swelled, vascular, of a 
deeply red color, and hot, with the outline of the advancing tooth per- 
ceptible, they should be freely incised to the tooth. If, on the contrary, 
the tooth is too deep to be felt, I would advise only a slight and super- 
ficial scarification in order to relieve the tension of the gum, and yet to 
avoid coming in contact with the tooth, which is sometimes injured by 
the lancet, when touched before the deposit of enamel is fully completed. 

The therapeutical management of the disease should be as simple as 
possible. The fewer drugs we can succeed with in the gastro-intestinal 
complaints of infants and children, the better, it seems to me. When, 
however, the diarrhoea continues for some days in spite of attention to 
the points already mentioned, we must resort to some of the means which 
have been found most useful in checking the inordinate action of the 
bowels. The most important are a careful employment of laxatives, and 
the use of opiates and astringents. I have generally commenced the treat- 
ment by the exhibition of a teaspoonful of castor oil, containing from half 
a drop to a drop of laudanum, for young infants, and two drops for older 
children. This dose alone given for two evenings in succession has often- 
times sufficed to effect the cure. Dr. West recommends very highly in 



302 SIMPLE DIARRH(EA. 

cases of simple diarrhoea, in which the evacuations, though watery, are 
faecal, and containing little mucus and no blood, the use of small doses of 
the sulphate of magnesia and tincture of rhubarb. His formula at one 
year of age is as follows : 

R. — Magnes. Sulphat., . . . . . . . gi. 

Tine. Rhei, £ij. 

Syr. Zingiber., gi. 

Aquse Carui, gix. — M. 

Dose — A teaspoonful. 

If the diarrhoea persists after this, we must resort to some of the 
astringents. The one most commonly employed is the chalk mixture, 
which is officinal in our pharmacopoeia. A teaspoonful of this is to be 
given after each loose evacuation, or three or four times a day. If the 
case prove obstinate, it will be found useful to add to each dose of the 
chalk preparation, a small quantity of laudanum or paregoric, or some 
astringent tincture, the best of which is the tincture of krameria. When 
the chalk mixture fails entirely, powdered crab's eyes will sometimes suc- 
ceed ; or we may resort to the aromatic syrup of nut-galls. The formulas 
and doses for both these remedies will be found in the article on entero- 
colitis. If the discharges are small and frequent, mixed with mucus and 
somewhat painful, it will be found that small opiate injections (from one 
to two drops of laudanum in a tablespoonful of prepared starch for young 
infants, and from three to six drops in double the quantity for older 
children), or the use of Dover's powder in combination with chalk or sugar 
of lead, will often succeed in arresting the disease. For further and more 
complete information in regard to astringents, I must refer the reader to 
the article on entero-colitis, where they will be fully discussed. 

The chronic form of simple diarrhoea which I have attempted to 
describe, occurring in children who have completed the first dentition, has 
always proved difficult to manage. From the experience I have had, it 
seems to me that the best mode of treating it is by proper regulation of 
the diet, and by the use of tonics and stimulants, and occasionally of 
opiates. I was led to adopt this plan in consequence of having failed 
entirely to control the symptoms by the treatment generally successful in 
simple diarrhoea, and by the opinion which I came at last to form, that 
the disease depended in great part on a loss of the digestive power of the 
stomach and duodenum. The diet must be adapted to the idiosyncrasies of 
the individual ; what we should seek is such an one as will be easily digested 
by the patient, the materials of which shall not appear in the stools, and 
one which does not manifestly increase, if it fail to moderate, the fre- 
quency of the discharges. The one which I have found to succeed best, 



TREATMENT. 303 

consists of boiled milk with stale bread for breakfast and tea, and the 
tenderest meats, as very fine beef, mutton, chicken, or birds, with rice, 
as the only vegetable, for dinner. If the child likes flour or rice pap, it 
may have either in place of the bread and milk. If it will take none 
of these, it may have milk, warm water and sugar, with bread ; or very 
delicate mush and milk, or milk toast. Should it refuse the dinner 
recommended above, we may substitute delicate soup, or some of the milk 
preparations. Between meals it ought to be allowed nothing but dry 
bread. All rich food, dessert, fruits, all vegetables except rice, candies 
and comfits, all kinds of cakes and hot bread, in fact, everything except 
the articles which I have mentioned or similar ones, ought to be rigidly, 
systematically, and perseveringly forbidden. Until this has been done 
for many days, or for several weeks, the disease has always, according to 
my experience, obstinately persisted. 

I have already said that I have not found the ordinary remedies for 
simple diarrhoea to exert much effect upon the disease. On the contrary, 
the treatment for dyspepsia, that is to say, a simple but nutritious diet, 
exercise, and the use of tonics and stimulants, have always removed it in 
a longer or shorter time. The tonics which I have employed are port 
wine, quinine, and iron. From a dessert to a tablespoonful of port wine 
was usually given in water three times a day, in connexion with iron. 
The preparations of iron used were Vallet's mass, of which from half a grain 
to a grain was given in pill three times a day ; or the solution of iodide of 
iron in the dose of first one, and then two drops, three times a day, in 
water, continued for one or two months. I have sometimes combined 
with each dose of the solution of iron, a drop of laudanum, especially if 
there were pain; or the opiate might be given by injection every evening. 
The quinine was generally administered alone in the dose of a grain three 
times a day, for one, two, or three weeks. It has not, however, proved so 
useful as port wine and iron. 

In the case attended with all the symptoms usually thought to indicate 
worms, the use of wormseed oil was followed by the expulsion of several 
very large lumbricoides. The child did not recover, however, for some 
weeks afterwards, and not until he had taken port wine and quinine for a 
considerable period. In other cases in which the verminous symptoms 
were also strongly marked, and in which the same remedy was given, no 
worms were expelled. 



304 GASTRITIS. 



SECTION II. 

DISEASES OF THE STOMACH AND INTESTINES, ATTENDED WITH APPKECTABLE 
ANATOMICAL LESIONS. 



ARTICLE I. 



GASTRITIS. 



General Remarks. — There are but two diseased states of the stomach 
attended with organic lesions, which demand our attention. These are in- 
flammation and softening. The medical authorities of the day are divided 
on the question, whether these conditions ought to be regarded as distinct 
and separate diseases, or whether softening is not merely a secondary le- 
sion, — the consequence of inflammation, or a cadaveric alteration. I shall 
consider both under the single head of gastritis or inflammation of the 
stomach, believing myself justified in so doing by the opinions of MM. 
Valleix, Rilliet and Barthez, Bouchut, Dr. Carswell, and other writers. 
The former author (Guide du Med. Prat., t. v. p. 118) says, " It seems to 
me, therefore, impossible, in the present state of the science, to distinguish 
during life, the cases of simple pale softening with thinning, from those 
in which softening is associated with evident traces of inflammation. " At 
page 145 of the same volume, he says : " A description of the symptoms 
of pale softening with thinning of the gastric mucous membrane might 
therefore be drawn; but as it would differ in no respect from that which I 
have already presented of chronic gastritis, it would be useless to repro- 
duce it here, or, to speak in clearer terms, I believe it results from the pre- 
ceding discussion, that we ought to confound, in regard to the symptoms, 
this form of softening with chronic gastritis, of which it is generally a 
consequence, either pathological, or cadaveric." Rilliet and Barthez treat 
of the two conditions collectively, after stating (t. i. p. 453), that a care- 
ful study of their cases failed to show any important differences between 
the symptoms of inflammation and softening of the stomach. The same 
authors, in speaking of softening (Loc. cit.), say: "Our cases have in 
effect led us to regard this affection merely as a secondary lesion, and not 
as a primary disease influencing the whole organism, revealing itself by 
special symptoms, and pursuing a regular course." M. Bouchut (Loc. cit. 
p. 231) says: "Never, indeed, in young children, does softening of the 
stomach constitute an isolated disease ; what has been asserted of that 
alteration belongs in fact to entero-colitis, which we have just described." 






GENERAL REMARKS — CAUSES. 305 

The authors of the Bib. du Med. Prat. (t. v. p. 600) are of opinion that 
it is doubtful whether softening ought to be regarded as a distinct and idio- 
pathic disease or not, but that it is a pathological and not a cadaveric 
lesion, they think cannot be contested. Dr. Carswell {Cyclop. Prat. Med. 
vol. iv. p. 13 and 15) says it may occur either as a pathological or post mor- 
tem lesion, and that in the former case it is a consequence of inflammation. 
He states that when softening of the gastro-intestinal mucous membrane 
is dependent on inflammation, " the symptoms are those of gastritis or 
gastro-enteritis," and adds : " It need hardly be observed that there are 
no symptoms referable to the state of softening which we have described, 
considered in itself, and as a termination of inflammation of the mucous 
membrane. " M. Barrier {Mai. de V Enfance, t. ii. p. 118), says he can- 
not agree with those who regard softening of the gastro-intestinal mucous 
membrane as a specific disease. He considers it to be a simple lesion of 
tissue " generally produced after death, and which, when it commences 
during life, never appears except as the consequence of an anterior mor- 
bid condition/' He supposes both gelatiniform and pale softening to be 
the result either of a merely chemical action of the gastro-intestinal fluids 
" which may commence before death, but which is chiefly exerted in the 
interval between the fatal event and the autopsy '" or to be a result of in- 
flammation or of one of the diacrises (diseases of the secretory function). 
Definition; Frequency. — By the term gastritis is meant inflamma- 
tion of the mucous coat of the stomach. It appears by the consent of 
all, to be of rare occurrence as an idiopathic affection in children. M. 
Valleix (t. v. p. 80) says, u We must conclude, therefore, that if gas- 
tritis occur in children, it is at least much more rare than in adults. " The 
author refers, in the above quotation, to the idiopathic form of the disease, 
which he regards as of rare occurrence, while he states that the secondary 
form is very frequent. MM. Rilliet and Barthez state {Loc. cit. p. 462), 
" that the lesions of the stomach are scarcely ever idiopathic." At page 
453, they assert that gastritis ought not to occupy an important place in the 
nosology of infancy : " Primary, it is almost always a disease of slight se- 
verity ; secondary, it is but an epiphenomenon of dangerous diseases, or 
the consequence of active medication ; lastly, if latent, it entirely escapes 
investigation." M. Bouchut says of the stomach (Loc. cit. p. 215), 
" This organ, which has been thought to play so great a part in the pro- 
duction of the diseases of children at the breast, does not at all deserve 
the attention bestowed upon it." 

Causes. — The causes of gastritis and softening of the stomach are not 
well understood. The only ones which seem clearly ascertained, are the 
action of irritating substances, and particularly of active medical agents, 
introduced into the organ ; the predisposing influence of certain diseases ) 

20 



306 GASTRITIS. 

and the solvent action of the gastric juice after death in the production of 
softening. MM. Eilliet and Barthez state that, in their experience, one 
of the principal causes of gastric inflammation and softening was the ap- 
plication of energetic remedies to the gastro-intestinal mucous membrane, 
and particularly the use of tartar emetic potions continued for several days 
in succession. They also mention the use of kernies mineral and croton 
oil as having had the same effect. It is proper to state, however, that 
these effects almost always occurred when the disease for which the remedy 
was given was secondary, and very seldom when it was idiopathic. 

The diseases in the course of which gastritis and softening of the stomach 
are most apt to occur are : cerebral affections, especially tubercular and 
simple meningitis, and apoplexy ; the eruptive fevers ; and inflammations 
of the thoracic and abdominal organs. 

Some observers go so far as to assert that the softening, which is generally 
confined to the mucous coat, but which extends in some cases to the others 
also, is always the result of a cadaveric change. Thus, M. Bouchut is of 
opinion that " it is a consequence of the acidity of the fluids contained in 
the digestive tube of young children, and these are exceedingly acescent in 
the disease to which we refer" (entero-colitis). M. Valleix concludes that in 
a certain number of cases there exist signs of inflammation which cannot 
be mistaken, and that this very inflammation may perhaps favor cadaveric 
softening in the parts attacked (t. v. p. 144). Rilliet and Barthez speak 
of inflammatory softening, but remark that in a large number of cases the 
alteration ought to be regarded as cadaveric. Dr. Condie (Bis. of Child. 
p. 186, 2d ed.) says, " we are still convinced, from the result of our own 
observations, that the gelatinous softening so frequently observed in 
children that have died of acute gastritis, is invariably the effect of intense 
inflammation of the mucous and other tissues of the stomach." Dr. 
Carswell, as has already been stated, believes it to exist both as a conse- 
quence of inflammation and as a post-mortem change. 

I believe that the indigestions of children are not unfrequently followed 
by slight gastritis, as I have often met with cases which have been followed 
by fever, disposition to nausea or vomiting, anorexia, and loss of digestive 
power for several days. 

Age seems to exert but little influence on the production of gastritis, 
which occurs indifferently in very young and in older children, while 
softening is generally acknowledged to be much the most frequent in 
infants, and in children under six years of age. 

Anatomical Lesions. — The pathological appearances in gastritis are 
redness, softening, thickening, ulceration, and the presence of pseudo- 
membranes upon the mucous membrane. Writers describe different forms 
of gastritis, according to the lesions found after death. The most important 



ANATOMICAL LESIONS. 307 

of these are the erythematous, pseudo-membranous, and ulcerative. The 
first of these, the erythematous, is characterized by redness, softening, and 
thickening of the mucous membrane. The redness, which is one of the 
most important features, may exist in the form of vascular arborizations, 
ecchymoses, or uniform coloration of a rosy, deep-red, brownish-red, or 
purple tint. Softening is thought by Rilliet and Barthez to be almost as 
important a sign of inflammation as redness, though they state that it may 
exist independently of inflammation. In most cases of erythematous 
gastritis, the softening is such that the mucous membrane may be re- 
moved with very slight force, and that it will yield no strips ; while in 
those which are very severe, the least scratch reduces the membrane to a 
pulp, and leaves the sub-mucous tissue exposed. When thickening is 
present it generally affects several neighboring points simultaneously, 
which project somewhat above the healthy tissue, and give to the inner 
surface of the organ a rough and unequal appearance, quite different from 
its ordinary smoothness and polish. In some few cases the thickening 
implicates the sub-mucous coat also, which becomes fibrous and resisting. 

The pseudo-membranous form of gastritis presents little whitish portions 
of false membrane, which are smooth, polished, and of an irregular shape, 
or thin, soft, rough, of a more or less deep yellow color, and which, isolated 
and distant from each other at first, become more abundant and extensive, 
and at last cover nearly the whole diameter of the organ. They are but 
slightly adherent to the mucous surface beneath. 

The ulcerative form of the disease is not a rare affection : it occurs in 
two varieties; one in which the ulcerations affect the follicles of the 
stomach, and the other in which the mucous membrane itself is ulcerated. 
The pathological lesions of the former variety will be fully treated of in 
the article on entero-colitis, and I shall therefore confine my remarks 
entirely to the latter variety. The ulcerations of the mucous membrane are 
of a circular or oval shape, or they occur in winding lines of various lengths, 
of from a third of a line to a line in width. The circular and oval ulce- 
rations are of various sizes, from the head of a pin to that of a small bean ; 
the smaller ones affect generally, but not always, the whole thickness of 
the mucous membrane, so that they rest on the sub-mucous tissue, while 
the larger implicate the sub-mucous tissue also, and therefore rest on the 
muscular coat. The edges of the winding ulcerations are usually soft and 
sometimes redder than the rest of the mucous membrane, whilst their 
depth is formed of the sub-mucous tissue, and is of a grayish-white color. 
At a more advanced stage, they increase both in length and breadth, unite 
after a time at their edges or extremities, and at last form extensive ulce- 
rations, in the midst of which are seen small portions of softened and 



308 GASTRITIS. 



tend 



reddened mucous membrane. The ulcerations of this form do not extend 
to the sub-mucous tissue, which, on the contrary, is generally thickened. 

I have next to describe softening of the stomach, which has been 
erected into a special and distinct disease, and about the true nature of 
which there is much discussion ; for while, as we have already seen, some 
observers assert that it is the result of acute inflammation, others ascribe 
it entirely to a post-mortem chemical action of the fluids contained in the 
stomach, and others again to inflammation, or some lesion of the nerves of 
the organ. In regard to this vexed question, I can merely express an 
opinion formed from the study of some of the best authorities upon the 
subject. That a large number of the cases of softening depend on cada- 
veric change, will not, it seems to me, admit of doubt. That some are the 
consequences of inflammation, is, I think, equally clear; whether the 
inflammation be the immediate cause, or whether, as M. Valleix surmises, 
it merely predisposes the tissues of the stomach to be more readily acted 
upon by the fluids which it contains. Whether there be a third set of 
cases which should be regarded as forming a distinct disease, in which the 
softening depends on some peculiar unknown condition of the organ, inde- 
pendent, however, of inflammation or of a chemical action of the gastric 
juice, seems to me very doubtful, and certainly far from being proved in 
the present state of knowledge on the point. 

Dr. Carswell (Loc. cit. p. 14) describes softening from inflammation as 
presenting various degrees. It may be such that the mucous membrane 
breaks as soon as it is seized between the fingers or forceps ; in the second 
degree, the edge of a scalpel or the finger passed lightly over it, converts it 
into a soft, somewhat opaque, creamy-looking pulp ; in the third and last 
degree, a stream of water a few inches in height carries it away. The 
softened portions may be quite pale, or they may present various shades of 
redness. The redness may be confined to the softened part, or extend to 
the neighboring portions, and may vary from a light rosy, bright, or dark 
red, to a purple or brown tint. In pale inflammatory softening, the color 
may be pale gray, or yellow, very much like the natural tint, or paler than 
usual. Dr. Carswell does not believe that inflammatory softening extends 
from the mucous to the other coats of the organ, so as to produce perfora- 
tion. He states, on the contrary, that the kind of softening which occa- 
sions that accident depends on the chemical action of the gastric juice. 

Dr. Carswell describes the appearances of post-mortem softening. The 
softening is generally met with in the fundus of the organ; its degree 
varies between a slight diminution of the consistence of the tissues, and one 
in which the mucous membrane resembles a quantity of albumen covering 
the sub-mucous coat ; the softened portion is generally very pale and trans- 
parent. The principal distinction between inflammatory and post-mortem 



ANATOMICAL LESIONS — SYMPTOMS. 309 

softening, is, that in the former the mucous membrane, " instead of being 
transparent, is more or less opaque, and even when it is completely dis- 
organized, it resembles a mixture of flour and water or milk, rather than 
an albuminous or gelatinous fluid. Such is in fact, the principal character 
of inflammatory softening of the mucous membrane in whatever organ it 
occurs ', whereas the transparent gelatiniform softening is never observed 
except where the chemical agent is formed by which it is produced, viz., 
in the alimentary canal, and in some of the neighboring organs, for the 
reasons which we have already given." 

The gelatiniform softening, which is that described by M. Cruveilhier 
as a disease peculiar to children, and which reduces the mucous membrane, 
and sometimes all the other tissues of the stomach, to the consistence of 
mucus or jelly nearly transparent in character, is, as we have just seen, 
supposed by Dr. Carswell to be invariably the result of post-mortem 
changes. MM. RAUiet and Barthez, on the contrary (Loc. cit. t. i. p. 
451), while they state that this form of the lesion scarcely ever coincides 
with inflammation in the same patient, surmise that it may have followed 
inflammation, though at the time of death all appearances of the latter 
have perhaps disappeared. They add, however, that " it is probable that 
softening, particularly the gelatiniform, may commence as such, but of 
this we have no proof." 

Symptoms. — It is very difficult to draw an accurate picture of the 
symptoms of inflammation and softening of the stomach, for the following 
reasons : that they have not as yet been studied with a sufficient degree 
of care ; that they are, as was stated in the early portion of this article, 
seldom idiopathic, but almost always secondary affections in the course of 
other maladies ; that the symptoms which betray them resemble so closely 
those of intestinal diseases, as to make it very difficult, if not impossible, 
to draw a distinction between the two ; and lastly, that in the great 
majority of cases, gastric complaints coexist with intestinal lesions. 

The most important symptoms are vomiting, diarrhoea, loss of appetite, 
thirst, epigastric tenderness, sometimes tension of the abdomen, and slight 
febrile reaction. 

Vomiting is the most important of the different symptoms of gastritis. 
It is not, however, according to MM. Rilliet and Barthez, invariably 
present. It was observed by them particularly in cases following the 
administration of active remedies, while in those which occurred sponta- 
neously, it was much less common. It shows itself pacticularly after the 
taking of food or drink. Sometimes when the stomach is empty, there 
is simply nausea and retching. In severe cases the vomiting is frequent, 
and accompanied by violent straining and pain. Diarrhoea exists in 
most cases, whether the attack be one of simple gastritis, or accompanied 



310 GASTRITIS. 

with enteritis. The appetite is generally lost or greatly diminished. 
TJiirst is commonly acute, and often intense. The tongue is described by 
some writers as being generally red, and sometimes smooth and glazed. 
The authors above quoted, state, on the contrary, that it presents nothing 
peculiar in most cases. It was generally moist, only slightly colored, 
covered with a white or yellow coat of variable thickness, and in some 
rare instances, red on the edges and tip, or gluey, or even dry and harsh. 
As a general rule, the abdomen is normal, according to the same authors, 
though in some cases there is more or less swelling and tension. Accord- 
ing to most writers there is generally tenderness on pressure in the epi- 
gastrium. Infants and young children are commonly restless and uneasy, 
as though in more or less pain, while those who are older complain of 
burning in the region of the stomach. It is well to remark that MM. 
Rilliet and Barthez state that tenderness on pressure often exists, not at 
the epigastrium, but in one of the iliac fossae, or at the umbilicus, even 
when the stomach alone is inflamed. The condition of the circulation, 
and indeed all the symptoms, depend so much upon the nature of the 
concomitant malady, that it is difficult to ascertain what are their real 
characters in simple gastritis. Most writers agree that fever usually 
accompanies the disease, and that it is commonly of the remittent type. 
It is certain, however, from other observations, that it does not always 
exist. 

In very violent cases there are added to the symptoms just described, 
those indicative of an adynamic state of the nervous system : — prostra- 
tion, cool or cold skin, with perspiration ; weak, rapid pulse ; singultus ; 
sometimes convulsions, and death. 

Diagnosis and Prognosis. — The diagnosis must rest chiefly on the 
existence and frequency of vomiting ; on the presence of epigastric pain 
or tenderness, of swelling and tension of the abdomen, and excessive thirst ) 
and on the absence of other disease which might account for the illness of 
the child. It is not possible, in the present state of knowledge, to draw 
a distinction between inflammation and softening, since, as we have seen, 
the symptoms of the two conditions are the same. 

The prognosis will depend on the severity of the gastric and constitu- 
tional symptoms, and on that of the concomitant disease, when the attack 
is secondary. When there is incessant and obstinate vomiting, so that not 
even water in small quantities can be retained after several hours of 
sickness ; when the tongue is red and glazed, or dry and brown, and when 
adynamic symptoms make their appearance, and emaciation makes rapid 
progress, it is much to be feared that extensive softening has taken place, 
and that the case will prove fatal. 

Treatment. — The two most important points in the treatment are the 



TREATMENT. 311 

withdrawal of whatever may have produced, or may tend to keep up the 
disease, if they can be detected, and strict attention to diet. Whenever, 
therefore, the symptoms have made their appearance after the exhibition 
of powerful drugs, as tartar emetic, ipecacuanha, or cathartics, their use 
ought to be instantly suspended. The child should be put on the 
strictest diet. If at the breast, it must be allowed to nurse only at rare 
intervals, and to take but little at a time. If fed on artificial diet, it 
should be restricted to barley or arrow-root water, or to very weak milk 
and water. Nothing solid and no rich liquid nourishment ought to be 
allowed, unless the child is in a state of weakness and debility from 
previous or concomitant disease, such as to make it absolutely necessary 
to endeavor to maintain its strength. Billard even recommends that 
the child be sustained by means of nutritive enemata, consisting of fari- 
naceous substances, while the digestive function is allowed a total rest. 

AntipMogistics are useful and proper when the disease occurs in a 
strong and healthy child, when it is associated with fever, and when there 
is nothing in the nature of the accompanying disease, if it be a secondary 
case, to prevent their employment. The most suitable mode of depletion 
is by leeches, which should be applied to the epigastrium. It is best to 
take but a very moderate quantity of blood, for fear of exhausting the 
patient. After the use of the antiphlogistic remedy, a warm bath will 
be found of great service in moderating the heat of the skin and render- 
ing the child more comfortable. Small pieces of ice ought to be put 
into the mouth occasionally, as a refrigerant, or small quantities of iced 
drinks may be allowed from time to time. As soon as the bleeding from 
the leech-bites, if leeches have been employed, has ceased, a warm light 
mush poultice to the epigastrium is a valuable and useful remedy. Some 
writers recommend the use of blisters to the epigastrium. I should much 
prefer a warm poultice or the occasional application of a mustard poul- 
tice. Dr. Condie recommends small doses of calomel, from a quarter to 
half a grain every hour or two hours. Opiates are useful in allaying 
nausea and vomiting, and appear to exert a favorable influence on the 
progress of the disease. 

When vomiting is frequent and troublesome, it may generally be allayed 
by the administration of lime-water and milk, given in teaspoonful quan- 
tities, every fifteen minutes or half hour ; by observing the precaution of 
allowing the food and drink to be given only in the smallest quantities 
(from a teaspoonful to a tablespoonful), and at considerable intervals ; by 
the application of warm cataplasms over the abdomen, or a spice-plaster to 
the epigastrium; or, lastly, by the exhibition of a few drops of laudanum, 
or paregoric, to be repeated if necessary. If the child becomes weak and 
exhausted, with coolness and abundant moisture upon the limbs, we must 



312 ENTERO-COLITIS. 

resort to the administration of some kind of stimulant. The best is 
probably weak brandy and water, given in very small quantities ; or we 
may employ wine-whey, or milk punch, or the aromatic spirits of harts- 
horn. 



ARTICLE II. 



ENTERO-COLITIS. 



General Remarks. — In treating of inflammation of the intestinal 
tube, I shall combine under one article inflammation of the large and 
small intestine, inasmuch as it appears from the researches of different 
observers that they coincide in the majority of cases. It would seem 
from the statements of Billard, that it is not unusual to meet with ente- 
ritis alone in the first year of life, for of 80 cases of inflammation of the 
intestinal tube, during that age, carefully observed by him, there were 
36 of enteritis; 30 of entero-colitis ; and 14 only of colitis. Bouchut, 
on the contrary {Loc. cit., p. 210), says that entero-colitis is almost pecu- 
liar to young infants. He adds that the principal morbid alterations of 
the disease are found in the large intestine, and, by extension, in the 
termination of the small intestine. MM. Rilliet and Barthez, whose 
observations apply to older children (over 15 months), say : " Enteritis 
by itself is rare ; it often coincides, on the contrary, with colitis : colitis 
without enteritis is very frequent " (T. i. p. 487). M. Legendre (Biblio- 
theque du Med. Prat., t. v. p. 649), found the large intestine alone dis- 
eased in 9 of 28 cases of diarrhoea, while of the alterations of the small 
intestines he says (p. 652), "Never isolated, but always united with 
similar lesions of the large intestine, these alterations are, in general, less 
serious than those found in the lower portion of the digestive tube." 

Another motive for describing the diseases of the whole intestinal tube 
under one head, is the difficulty, not to say impossibility, of recognising 
during life the affections of its different portions. Billard (p. 428), re- 
cognises this difficulty, for he says : " In consequence of the impossibility 
we have found to exist of tracing with exactitude the series of symptoms 
proper to inflammation of the different portions of the digestive tube, we 
shall content ourselves with presenting an analytical sketch of the causes, 
symptoms, and ordinary course of inflammation of the mucous mem- 
brane of the intestines in general." MM. Rilliet and Barthez and M. 
Bouchut, also describe enteritis and colitis together, under the title of en- 
tero-colitis. 



SYMPTOMS — FORMS. 313 

Writers make several divisions or forms of disease of the intestinal 
mucous membrane. Of these, the most important are the erythematous, 
pseudo-membranous, and follicular inflammations, and softening, and gan- 
grene. The whole subject is involved in much obscurity, in consequence 
of the variety of the lesions, and the different views as to their nature, 
which have been adopted by different authors. The follicular form of dis- 
ease particularly, has given rise to a great deal of discussion, some as- 
serting that it is not an inflammation, but a simple functional derangement 
of the secretory apparatus of the bowel, while others as strenuously main- 
tain its inflammatory nature. In the present article, I shall, under the 
title of entero-colitis, devote particular attention to the erythematous and 
follicular forms of inflammation, and to softening of the mucous coat of 
the bowels : the pseudo-membranous form of inflammation and gangrene 
are rarely met with, and are therefore of much less importance. 

Definition j Symptoms ; Frequency ; Forms. — By the term entero- 
colitis is meant inflammation with its attendant lesions, ulceration, soften- 
ing, thickening, pseudo-membranous exudations, and gangrene, of the intes- 
tinal mucous membrane. 

Under this title I shall describe the different kinds of diarrhoea treated 
of by Underwood, Eberle, and Dewees, under the titles of bilious, mucous, 
and chronic diarrhoea, and by Dr. John Cheyne (Essays on Dis. of Child- 
ren; Edinburgh, 1801-2), under that of Atrophia Ablactatorum orWean- 
ing-brash. 

Entero-colitis is one of the most frequent of children's diseases. Du- 
ring the five years from 1844 to 1848, inclusive, there were 4204 deaths 
from diseases of the digestive organs in this city, including amongst these, 
diarrhoea, dysentery, cholera infantum, inflammation of the stomach and 
bowels, marasmus, aphthae, worms, colic, and various other affections of the 
stomach and bowels. Of the 4204, 2717 were from diarrhoea, dysentery, 
cholera infantum, and inflammation of the stomach and bowels, and as en- 
tero-colitis exists in by far the greater part of these diseases, we may un- 
derstand how extremely frequent an affection it is. The deaths from af- 
fections of the digestive organs during the period referred to, constituted 
not quite a fourth of the whole mortality under fifteen years of age ) whilst 
those from diseases of the nervous system were rather less in number, 
and those from diseases of the respiratory organs rather more than a fifth. 
It appears, indeed, that entero-colitis, in the form of diarrhoea, dysentery, 
cholera infantum, or what is called in the bills of mortality, inflammation 
of the stomach and intestines, is by far the most fatal disease of childhood. 
We may appreciate yet more accurately the importance and frequency of 
the disease, by reference to the statements of MM. Rilliet and Barthez, 
who say (t. i. p. 483), that, taking into consideration all the cases they ob- 



314 ENTERO-COLITIS. 

served, including tubercular cases, they find that of every two children 
that die, one presents a more or less serious lesion of the large intestine. 
They add; " If it be recollected that this holds true particularly in regard 
to younger children, it will be seen that it is rare for a child to die between 
two and five years of age, without having either colitis or softening of the 
large intestine. " Bouchut states that entero-colitis is one of the most 
dangerous affections of children at the breast; " It is the most common of 
all those incident to that age/' (p. 210.) 

I shall describe two forms of the disease, the acute and chronic. The 
acute form is accompanied by active and inflammatory symptoms from 
the first, and runs its course in a few days or weeks ; the chronic form is 
unaccompanied by acute symptoms, and lasts several weeks or months. 

Causes. — The most frequent cause of enteritis in infants, the one most 
clearly and positively ascertained, is, it seems to me, improper alimenta- 
tion. This may consist either of an unhealthy milk of the nurse, or, 
what is much more common, improper artificial nutriment. The kind of 
food most apt to produce the effect is one composed exclusively or in con- 
siderable proportion of some of the feculent substances, which constitute 
so large a portion of the diet of children throughout the civilized world. 
To prove the truth of this assertion it is only necessary to quote the 
opinions of those who have most carefully studied the subject. M. 
Valleix (Guide du Med. Prat., t. iv. p. 60, 61, and Bulletin Gen. de 
Therap. y article Acute Enteritis of Adults and new-born Children, March, 
1845) clearly asserts that the most frequent cause of muguet, which he 
believes to be essentially connected with enteritis, is a too exclusively 
feculent alimentation. In the article last cited, while speaking of the 
great importance of this cause, he says : " What proves that my assertion 
is not hypothetical is, first, that all the deaths from enteritis in children 
that I have seen, occurred in those who had been placed upon this kind of 
regimen, and second, that the disease did not occur in any of those 
observed by me in private practice for whom I had directed an exclusively 
milk diet up to four, five, or six months of age." He adds that M. Trous- 
seau has arrived at similar opinions, after studying the same diseases at 
the Necker Hospital; and that he, on account of the danger of a system of 
diet disproportioned to the digestive powers, recommends that children 
be confined almost exclusively to the breast until after the first den- 
tition is completed. Barrier, speaking of the follicular diacrisis (Loc. cit. 
t. ii. p. 40), states that the artificial food given to children at the period 
of weaning is a frequent cause of the affection, and that of all the different 
kinds of food habitually employed at that period, feculent substances are 
the most injurious. I have, myself, frequently known entero-colitis to 
follow the employment of artificial diet either alone, at the period of wean- 



CAUSES. 315 

ing, or in children who were partly nursed. Children fed wholly on arti- 
ficial diet from birth, rarely escape, according to my experience, attacks of 
the disease, which in many prove fatal. I have, on several occasions, 
seen children recover rapidly from the disease, after suffering more or less 
for weeks, by the suspension of a diet consisting wholly or in too large pro- 
portion of farinaceous materials, and the substitution of one composed of milk 
and cream, prepared with gelatine, and containing a very small quantity 
of arrow-root, rice, or wheat flour. (See article on thrush, page 262.) It 
is not merely the quality, but the quantity also of artificial food that 
proves injurious to infants. Over-feeding has always been recognised as 
a fruitful source of bowel complaints in early life. Another cause is the 
preparation of the food in too thick and rich a manner, thereby overtasking 
the stomach, intended during the early months to receive only the thin 
milk supplied by nature. The custom, therefore, of feeding infants on 
thick oatmeal gruel, with but little or no milk, on what is called cracker 
victuals (pounded crackers with water and sugar, or milk), on thick bread 
and milk, on preparations of rice of too solid a nature, or indeed, on any 
kind of diet not consisting chiefly of milk, and in which feculent sub- 
stances enter merely as secondary constituents, may safely be asserted to 
be the most frequent cause of the disease under consideration. 

An unhealthy character of the milk of the nurse is also known to be a 
cause both of simple diarrhoea and entero-colitis. When the granules 
which exist as a physiological element in the colostrum secreted during 
the first few days after childbirth, continue to be secreted after that period, 
the infant is almost certain to suffer from entero-colitis, and not unfre- 
quently to die, unless weaned or transferred to another nurse. It is 
said, also, that when the mammary secretion is acid, instead of alkaline, 
when it contains mucus or pus globules, when the nurse is liable to vivid 
moral emotions of any kind, or when addicted to intemperance, the child is 
very apt to suffer either from the disease under consideration, or from 
simple diarrhoea. 

After the causes just enumerated, the one which appears to exert the 
strongest influence is dentition. That the evolution of the teeth, though a 
physiological process, is a powerful predisposing cause of diarrhoea and 
enteritis, there cannot remain a doubt at the present time. It is one re- 
cognised by many of the most able writers and observers of the day, and 
by most practitioners. Rilliet and Barthez agree with Trousseau in the 
opinion that the simple diarrhoea so apt to occur in children at the epoch 
of the first dentition, is often the origin of chronic intestinal lesions which 
finally reduce them to extreme debility and emaciation. They say that 
careful investigation will generally show that nearly all the cases of inflam- 
mation and softening date either from the epoch of dentition, from the 



316 ENTERO-COLITIS. 

period of weaning, or from the time at which some considerable change in 
the character of the regimen was made. M. Bouchut states that of 110 
children in whom the first dentition was going on, 26 escaped any indispo- 
sition, 38 suffered from restlessness, colics, and occasional diarrhgea, so 
mild as to excite no alarm in the parents, whilst 46 had abundant diarrhoea. 
In 19 of the last series it appeared coincidently with the fluxion of the 
gums, occurring at the time of emergence of each tooth, and disappearing 
entirely in the intervals; in the remaining 28, in all of which the process 
of dentition was difficult, the diarrhoea persisted and gradually assumed 
the characters of entero-colitis. M. Legendre and M. Barrier (Loc. cit.) 
both agree in ascribing very great effect to the influence of dentition in 
the production of diarrhoea and entero-colitis. The former asserts the 
diseases referred to to be much the most frequent between the ages of six 
or seven months, and two or two and a half years, which includes exactly 
the period occupied in the first dentition, while they are only met with 
exceptionally after three years of age. 

The act of weaning is very apt to result in the production either of 
simple diarrhoea or entero-colitis, in consequence, no doubt, of the irrita- 
tion set up in the gastro-intestinal surface, by the change of food made 
at the time. The diarrhoea which occurs at this period was formerly, and 
is still, not unfrequently, called weaning-brash. Dr. Stokes (Cyclop, of 
Med. Art. Enteritis) says of this disease that it " is manifestly an acute 
enteritis, produced by the change of food, and in which nature seeks to 
relieve the inflammation by a super-secretion." 

We may conclude, therefore, in the words of Rilliet and Barthez (Loc. 
cit. p. 541), " that the greater number of cases of entero-colitis in young 
children are caused by dentition, weaning, and any very sudden change of 
regimen or other hygienic conditions. " 

Various other causes are cited by writers. Amongst the most important 
are excessive heat at certain seasons ; unfavorable hygienic conditions as 
to habitation, ventilation, clothing, cleanliness, and want of exposure to 
the air ; the existence of certain diseases ; and a lymphatic constitution, 
or one debilitated and exhausted by any cause. 

That heat of weather acts as a predisposing cause to entero-colitis and 
diarrhoea, is clearly shown by the fact of the much greater prevalence of 
these diseases, and particularly of cholera infantum or summer complaint, 
during the three summer months. M. Valleix has shown, also, that the 
acute enteritis of new-born children is much more prevalent during the 
warm, than the cold season of the year. 

It is scarcely necessary to do more than state the fact that the unfavor- 
able hygienic conditions above referred to, act as predisposing causes to 
the disease. This is clearly shown to be true by the evidence of many 



CAUSES — ANATOMICAL LESIONS. 317 

writers, and by the very extensive prevalence and great fatality of the 
affection in hospitals, and amongst the children of the destitute classes of 
society in cities and towns. 

Entero-colitis is prone to occur as a secondary affection in many of the 
acute diseases of children. It is by far the most common in the course 
of the eruptive fevers, particularly measles, and in that of typhoid fever. 
It is also a frequent complication of the latter stages of pneumonia. 

That children of feeble constitution and lymphatic temperament are 
more disposed to the disease than others, is sufficiently proved by the 
evidence of various observers. Lastly, that the incautious and excessive 
use of perturbing systems of medication, addressed to the digestive tube, 
often occasions diarrhoea and entero-colitis, is fully proved by the re- 
searches of MM. Rilliet and Barthez, and by my personal experience. 

Anatomical lesions. — It has already been stated that the alterations of 
the large intestine are, as a rule, much more frequent and serious than 
those of the small intestine. It appears from the researches of 11^1. 
Rilliet and Barthez, and Legendre, that enteritis rarely exists alone, 
whilst colitis, by itself, or combined with enteritis, is quite frequent. M. 
Legendre states that inflammation of the small intestines never occurs 
without corresponding lesions of the large bowel, while in 28 cases of 
diarrhoea, he found the large intestine alone diseased in 9. From a table 
of different intestinal lesions, given by MM. Rilliet and Barthez {hoc. cit. 
t. i. p. 488), it appears that they have met with 45 cases of erythematous, 
pseudo-membranous, ulcerative or pustular enteritis; with 113 of the 
same forms of colitis; with 90 of follicular enteritis; 64 of follicular 
colitis ; and with 28 of softening of the small, and 35 of softening of the 
large intestine. It seems clearly established, therefore, that inflammation 
of the large is considerably more frequent than that of the small intes- 
tine, and much more apt to exist alone. 

It has already been stated that my remarks would be confined chiefly 
to the erythematous and follicular forms of inflammation, and to softening 
of the intestines. But even here we are met by a difficulty, since some 
writers confound the two forms of inflammation together, and regard them 
merely as different degrees of the same alteration. Such is the view 
taken by the English authors that I have consulted, and by MM. Legen- 
dre and Bouchut. MM. Rilliet and Barthez, on the contrary, describe 
the anatomical lesions of the two forms separately, with great care, but 
confound them together in their description of the symptoms. Barrier, 
as we have already seen, makes of the follicular form a disease altogether 
different from ordinary inflammation, and calls it follicular diacrisis. For 
my own part, I am strongly disposed to believe that erythematous and 
follicular inflammation, and softening of the intestinal mucous membrane, 



318 ENTERO-COLITIS. 

are indeed, as asserted by Legendre and Bouchut, and by some English 
writers, merely different degrees of the same disease. That they very 
often coincide in the same individual is proved by the observations of 
different authors, and particularly by those of MM. Eilliet and Barthez, 
who have given a table of 185 autopsies (t. i. p. 488), showing the exact 
manner in which they are united in the same individual. From this 
table it appears that of the whole number, there were only 2 cases of 
enteritis, 32 of colitis, 11 of entero-colitis, 12 of follicular enteritis, 3 of 
follicular colitis, and 13 of follicular entero-colitis, existing each alone, 
uncombined with other lesions ; there were also 18 cases of softening of 
the small or large intestine without other alterations; while the remaining 
cases, 97 in number, consisted of the different lesions enumerated, va- 
riously combined in the same individual. 

Inasmuch, however, as the relation of the two forms to each other is 
not as yet fully determined, and as a separate description will be more 
accurate than one in which the two are mingled together, I shall adopt 
the former plan, stating, however, the fact which is acknowledged by all, 
though variously interpreted, that they very often coexist in the same 
individual. 

Erythematous inflammation is generally slight, both in degree and 
extent, in the small intestine. In some few cases it is general, and then 
appears in the form of redness produced by arborizations. In other in- 
stances it appears in spots of more or less vivid inflammation, which may 
extend throughout the small intestine, or be limited to certain portions. 
Though sometimes confined to the upper part of the bowel, constituting 
duodenitis, it is much more apt to exist in the lower part of the ileum, 
where it generally assumes more serious characters than above. At the 
latter point it appears in the form of more or less bright injection with 
tumefaction, and sometimes softening, of the mucous membrane. 

The large intestine is generally contracted and lessened in size, accord- 
ing to Bouchut. This condition is mentioned also by Dr. Cheyne, in his 
remarks on atrophia ablactatorum (Loc. cit.), and by Dr. Eberle as exist- 
ing in a case examined by himself (Loc. cit,, p. 239), in which he found 
the whole length of the colon contracted to a size that scarcely admitted 
the little finger. The erythematous inflammation generally presents itself 
in the shape of arborizations or spots, and seldom of bands. The inflam- 
mation is generally most acute in the caecum, descending colon, and 
rectum, particularly the latter, where it often assumes great severity. 
The color of the mucous membrane varies from a pale rosy to a deep 
scarlet tint, which is either uniform, and dependent on minute injection of 
the capillaries, or which in some cases affects only the summits of the folds 
of the mucous tissue* The mucous membrane is often thickened, and still 



ANATOMICAL LESIONS. 319 

more frequently softened. Of the latter alteration, however, I shall speak 
after a time j while of ulceration, which is still more common, notice will 
be taken under the head of the follicular form of the disease. 

Follicular Inflammation. — The follicular apparatus of the intesti- 
nal tube consists of isolated and agminated glands. The isolated follicles 
are abundant in the stomach, and exist throughout the length of the in- 
testinal tract. They are most abundant in the superior and inferior por- 
tions of the small intestine, less so in the middle, and numerous again 
in the large intestine, particularly the rectum. The agminated follicles, 
as is well known, are found chiefly in the ileum along the free edge of the 
intestine, and become more and more numerous as we approach the caecum. 
The isolated follicles are not very distinct in their normal condition, but 
undergo various changes when affected with disease. M. G-endrin {Trait. 
Philosophique de la Med. Prat. t. iii. p. 6) says that they are scarcely so 
large in their normal condition as the head of a small pin, and that they 
consist of little white bodies, upon which we can rarely distinguish with 
the naked eye, but always with a lens, a grayish point, which is the excre- 
tory orifice. He distinguishes the crypts into simple and compound. The 
simple have just been described ; the compound are formed of an agglo- 
meration of several simple crypts or cryptiform granulations, having a 
common reservoir and excretory canal. It must be observed that he does 
not mean by the compound crypts, the glands of Peyer, which he else- 
where describes under the title of cryptous plaques. He states that the 
simple crypts are found in the stomach, especially the pyloric half and 
along the great curvature, in the duodenum, and in the jejunum, in such 
quantities that they seem to be almost confluent. As we descend into the 
ileum they become larger and less frequent. They are rare in the large 
intestine, where instead of them are found the compound crypts, which 
are there very numerous. The latter exist also in the stomach and duo- 
denum, but are rare in the small intestine. 

The alterations of the follicular apparatus of the gastro-intestinal mu- 
cous membrane, constituting the follicular inflammation of several writers, 
may be referred to under two heads, first, increased development without 
apparent inflammation, and second, inflammation, with or without dis- 
organization. 

The first condition, or that of increased development without evident 
inflammation, presents the following characters. The isolated glands have 
become enlarged, and seem therefore more numerous than in the healthy 
condition j they appear in the form of lenticular grains seated in the tex- 
ture of the mucous membrane, sometimes projecting from its surface, some- 
times not, and in other instances appearing to be situated beneath it ; the 
excretory orifices of the glands are often enlarged and tumid, and easily 



320 ENTERO-COLITIS. 

distinguished under the form of a grayish or blackish point in the middle 
of the gland ; in other cases the orifices cannot be distinguished until, 
slight pressure is made upon the crypts, when a drop of mucus may be 
seen exuding through the open point. The color of the follicles in this 
condition is dull white, rosy, or yellowish ; they are generally from a third 
to two-thirds of a line in diameter. Dr. Horner (Am. Jour. Med. Set., 
Feb. 1829) speaks of them in this state of development as resembling 
" small grains of white sand sprinkled over the mucous membrane, and 
about the size of a millet seed." 

The agminated glands or plaques of Peyer are found in the same state of 
increased development. They are tumefied ; they project above the level of 
the surrounding mucous membrane, and are evidently enlarged, without, 
however, always presenting evidences of inflammation. 

M. Barrier describes another condition of the follicles, which is met 
with chiefly in the large intestine. This is an enlargement of the orifice 
of the gland, which will easily receive a small probe, and sometimes mea- 
sures near half a line in diameter. This dilated orifice, which might rea- 
dily be mistaken for an ulceration, leads into a little cavity, which is the 
follicular sac itself. 

Authors are very much divided as to whether the alterations of the fol- 
licles just described ought to be regarded as the result of inflammatory 
action or not. Billard says it is not of " evident inflammatory nature j" 
and in another place, that he does not consider it a " frank inflammation 
of the muciparous follicles," but as " a degree intermediate between the 
normal and inflammatory state." M. Barrier, on the contrary, says that 
these alterations are evidently not of an inflammatory nature, and that 
they do not entitle the disease to the name of gastro-enteritis or colitis. 
He, therefore, follows M. Gendrin, and expresses the condition in which 
they occur, by the word diacrisis, or altered secretion. MM. Rilliet and 
Barthez believe the alteration to depend upon inflammatory action, with- 
out, however, affirming it positively. The authors of the Bibliotheque du 
Medecin Praticien (t. v. p. 657), state that it cannot be doubted that in- 
flammation plays some part in the anatomical alterations of the secretory- 
apparatus of the digestive tube just described, and of those we shall speak 
directly. For my own part, I am clearly of opinion that they are in all 
probability the first stage of inflammation ; for, as we shall presently see, 
when the condition persists for some length of time, the follicles almost 
invariably become ulcerated and surrounded by patches of inflammation, and 
though it is possible, as M. Legendre supposes, that the surrounding in- 
flammation may be the result of ulceration of the crypts, it is difficult 
to understand how that ulceration could occur independently of inflam- 
mation. 



ANATOMICAL LESIONS. 321 

The other changes we have to notice are evident inflammation and ul- 
ceration of the follicles. M. Legendre (Billioth. du Mid. Prat., t. v. p. 
650) says that after the morbid development of the follicles (which he 
calls the first degree or stage of disease) has existed for some time, if the 
causes which produced it continue in action, the alteration becomes the 
point of departure of numerous ulcerations, which are deeper in proportion 
to their time of duration. The researches of the French observers prove 
that the alterations, and particularly the ulcerations, of the follicles are 
more frequent and occur to a greater extent, in the large than in the small 
intestine. M. Legendre states that in 28 cases of diarrhcea, he found the 
large intestine alone diseased in 9 ; while of the small intestine he says, 
that the morbid modifications of its follicular apparatus never occurred 
alone, but were always combined with similar lesions of the large bowel, 
and, moreover, were generally less considerable than those of the latter : 
from these circumstances he is led to infer that in chronic diarrhoea, the 
small intestine is last attacked. A reference to the dissections of Dr. Hor- 
ner, and especially to those of Dr. Hallowell (Am. Journ. Med. Sci., July, 
1847), will show that these statements as to the seat of the follicular 
lesions hold good also in regard to cholera infantum. 

I shall first describe the ulcerations as observed in the large intestine. 
In the forming stage they appear in the form of superficial, circular ero- 
sions, from one to two-thirds of a line in diameter, generally neither in- 
jected nor protuberant. In this stage they may easily escape observation 
under superficial examination. Each of these ulcerations will be found 
developed upon a follicle. When more advanced, the mucous membrane 
is seen to be riddled, not with superficial erosions, but with true ulcera- 
tions, of a perfectly circular shape, affecting the whole thickness of the 
membrane; their edges, either pale or injected, circumscribe a small, gray- 
ish, semi-transparent corpuscle, of the size of the head of a pin, from 
which by pressure a drop of opaque, grayish mucus may be made to escape. 
In a still more advanced stage may be observed, sometimes in the last 
half of the intestine, but most frequently in the rectum only, deeper and 
larger ulcerations, which, when isolated, are perfectly circular, and mea- 
sure from a line to a line and a half in diameter, but which, from the run- 
ning together of two ulcerations, are sometimes irregular in shape, and of 
a larger size. The bottom of these ulcerations is formed of the sub-mu- 
cous, and often of the muscular tissue \ their edges are of a slate-gray 
color, thickened, and sometimes detached ; their depth is occasionally co- 
vered with a pultaceous, apparently pseudo-membranous layer, of a grayish 
white color. That the large and deep ulcerations just described, even 
when most extensive, are originally seated in the muciparous crypts, is 
proved by the presence amongst them of other ulcerations of more recent 

21 



322 ENTERO-COLITIS. 

date, and smaller size, which present in their centres a well-marked mu- 
cous follicle, and show clearly the origin of the larger and more advanced 
ulcerations. 

The mucous membrane itself presents different appearances according 
to the date and degree of the ulcerations. When the superficial erosions 
alone are present, it sometimes retains its ordinary normal grayish tint, 
but, more generally, it is of a rose-gray color, dotted with little patches of 
a deeper red, produced by very fine arborizations ; or, lastly, it presents a 
very minute red punctuation. Besides the injection, there are usually 
softening and thickening of the membrane. The redness, softening, and 
thickening, are all most considerable around the deep ulcerations above 
described. 

Small Intestine. — The lesions of the follicles of the small intestine are 
generally much less considerable than those of the large. Simple morbid 
development of the isolated and agminated follicles are almost the only 
alterations that are found. The follicles, especially the agminated, often 
have the appearance of being ulcerated, but a careful examination will 
generally show that this is not the case. The appearance depends on the 
fact of the orifices of the glands being dilated, upon unequal tumefaction 
of the surrounding mucous membrane, and upon the presence in the 
plaque of small, irregular, grayish points, consisting of a pultaceous 
matter, which makes the plaque look more projecting than usual. If, 
however, the pultaceous layer be gently rubbed with a piece of linen, it 
can be easily detached, when the mucous membrane beneath is found red, 
softened, and thickened, but not ulcerated. The lining membrane of the 
small intestine seldom presents any important changes in follicular dis- 
ease. It usually retains its natural color, consistence, and thickness. 
"When, however, the crypts are much altered, it is generally red, softened, 
and thickened. 

Softening of the mucous coat is very generally present to a greater or 
less degree in entero-colitis. Bouchut states that in young infants the 
last eight or ten inches of the ileum is the portion of the small intestine 
generally diseased. The softening is sometimes accompanied by inflam- 
mation and thickening. In two cases he found the mucous membrane 
white and opaque, with an entire destruction of its consistence from the 
pylorus to the ileo-caecal valve. In the large intestine its consistence is 
considerably modified, so that it is generally impossible to obtain strips. He 
adds that this condition always coincided with vivid redness. Legendre 
says that the mucous membrane of the small intestine is not softened 
unless the alterations of the muciparous crypts are very marked and ex- 
tensive. In the large intestine he found the mucous tissue slightly soft- 
ened around ulcerations of recent origin and slight extent, while around 



SYMPTOMS. 323 

those of greater depth, the softening existed in a much more advanced 
degree. MM. Billiet and Barthez, whose observations were made in 
children over fifteen months old, describe both pale and gelatiniform soft- 
ening as frequently occurring in the small intestine. They say that it 
generally occupies the whole extent of the mucous membrane from the 
duodenum to the ileo-cascal valve, that it is rarely limited to the inferior, 
and still more rarely to the superior portion of the bowel. Both varieties 
are common also in the large intestine, and they more frequently affect the 
whole than only a part of that bowel, though they are sometimes limited 
to the caecum, colon, or rectum. 

Symptoms; Duration. — In infants the acute form of entero-colitis 
generally begins with restlessness and fretfulness. The mother observes 
that the child sleeps less than usual and for shorter periods, and that its 
sleep is uneasy and broken by sighing or moaning, or by occasional ex- 
pressions of pain flitting across the face. It takes the breast less fre- 
quently, and is satisfied to nurse for a shorter time, showing thereby an 
evident diminution of appetite. At the same time it is apt to reject the 
milk which it has taken in larger quantities than usual, and this is often 
observed to have a very acid smell. After these symptoms have lasted a 
few days, and sometimes without them, the peculiar symptoms of the 
disease, the diarrhoea and other abdominal symptoms, make their appear- 
ance, and are accompanied by febrile reaction in most cases. 

In older children the acute form may come on suddenly, with diarrhoea, 
loss of appetite, thirst, sometimes vomiting, abdominal pain and fever, 
from the first; or, as happens very frequently, the case begins with slight 
diarrhoea, unaccompanied by fever, or other signs of sickness, and it is 
not until after several, or eight, ten, or even more days, that signs of 
inflammation make their appearance. 

After the disease is established, the most important symptoms are. the 
following. The diarrhoea, which is the most prominent and characteristic, 
presents various characters. In order to appreciate this symptom as its 
importance requires, the practitioner ought always to see the napkins of 
the child at least once, and often more frequently, in the day. It exists 
in almost all cases of entero-colitis, in the erythematous and follicular 
inflammations, and in the ulcerations and softening which accompany or 
succeed simple inflammation. It is seldom absent, and yet that it is so 
sometimes, is proved by the facts mentioned by MM. Billiet and Barthez, 
who state that they have calculated, from their cases, that it is wanting 
in about one of every twelve cases of inflammation or softening of the 
intestine. They add, however, that it is absent only in slight attacks, 
and is always present when the disease is severe. It varies greatly as to 
the frequency, abundance, and character of the stools. It varies also in 



324 ENTERO-COLITIS. 

its mode of progress, so that it presents great differences as to all these 
points from day to day, and at different portions of the same day. We 
may remark in general, however, that in proportion to the severity of the 
inflammation, so is the diarrhoea violent and constant, and that it usually 
increases as the signs of inflammation become more and more marked. 
It is rare to have severe diarrhoea when the anatomical lesion is of slight 
extent, though this does sometimes happen. The number of the stools, 
as has been stated, is exceedingly variable. This depends in great mea- 
sure upon the violence of the case ; for, while in those which present the 
symptoms of an inflammation of small extent, the stools seldom amount 
to more than six or eight a day, in those in which the evidences of more 
extensive and severer inflammation are present, there will be fifteen, 
twenty, twenty-five or even more per diem. The consistence of the stools 
may vary between that which characterizes them in a state of health, and 
that of the thinnest serous fluid. The materials of which they are com- 
posed consist chiefly of mucus, bile, serum, small portions of feculent 
matter, portions of undigested caseum or other food, and blood. M. Bou- 
chut {Loc. cit. p. 219), describes those of very young children as pre- 
senting the following characters. 

1. They are semifluid, homogeneous, greenish, and similar to cooked 
vegetables; neutral. 

2. Semifluid, homogeneous and green ; often acid. 

3. Semifluid, heterogeneous, greenish, and mixed with yellowish frag- 
ments of ordinary faeces; neutral. 

4. Semifluid, heterogeneous, greenish, and mixed with fragments of 
undigested caseum ; acid. 

5. Diffluent, greenish, heterogeneous, composed of a large quantity of 
water in which float yellowish and greenish, or whitish particles ; acid. 

6. Diffluent, greenish, like the preceding, and mixed with gas of a 
mawkish and sometimes sourish smell. 

7. Diffluent, completely serous. 

8. Bloody stools are very rare at this age. We have met with them 
once only in a child affected with acute hepatitis. 

Such are the appearances of the stools in children who have not com- 
pleted the first dentition. After the epoch of the first dentition the disease 
becomes much more rare, and when it occurs, is generally of a milder 
character, so that the discharges differ less from their healthy characters. 
Under these circumstances, they are usually less frequent, not often 
exceeding six, eight or ten in the day, and retaining generally their yellow 
color or becoming brownish; they are commonly of a semifluid consis- 
tence, and may be called- bilious. When, on the contrary, more frequent, 
they become fluid, abundant, mixed with mucus, and are either of a light 



SYMPTOMS. 325 

yellow or brownish, or more rarely, of a greenish color. In some cases 
there are, in addition to the substances mentioned, pus, which indicates 
suppuration of the lower portion of the intestine, and fragments of false 
membrane. Moreover, it is very common in older children to observe 
traces of blood in the stools, sometimes in considerable quantities. I may 
remark that I have several times met with stools containing blood in 
children within the year, but much less frequently than after that age. 
The presence of blood generally coincides with small and frequent stools, 
attended with much straining, and often severe pain, and almost always 
indicates follicular inflammation and ulceration of the large intestine. 

The serous fluid alluded to sometimes constitutes the whole of the 
discharge, so that the napkins are merely wetted through, without any or 
but a very small quantity of solid matter being left upon them. This 
kind of stool is very frequent in the cholera infantum of this country. 
The odor of the stools is important. In the beginning, while the dis- 
charges still retain some of their natural characters as to color and con- 
sistence, it is often very offensive, but as the case goes on, and the greenish 
color predominates, it is either sour, or becomes very slight. In some 
violent cases, in which the discharge consists of a watery, dark-brown 
fluid, the odor is fetid. 

After diarrhoea, the most important symptoms are those which concern 
the form, size, and tension of the abdomen, and the presence or absence 
' of pain or tenderness on pressure. In infants the abdomen is more dis- 
tended than usual; but, according to Bouchut, the tension depends on 
the muscular effort made by the child to resist the hand of the physician. 
He says that when it is carefully examined, while the attention of the 
child is attracted in some other direction, it is found to be soft and supple, 
and rarely painful to the touch. In older children it is, in many acute 
cases, but not in all, enlarged, sometimes tense and sonorous, and very 
generally painful to the touch. The seat of pain is variable, but gene- 
rally it is in one of the iliac fossse or at the umbilicus. It is seldom acute, 
though the child not unfrequently shrinks away and cries out, as though 
it were excessive, from fear of the examination. It is easy to distinguish 
when the pain is real and when apparent, by withdrawing the attention 
of the child, by some device, from the examination, in which case it will 
cease to notice the palpation; or by touching some other part of the body, 
when, if the crying and shrinking depend on fear or nervous excitation, 
they will be as violent as when the abdomen is touched. Pain to the 
touch is an important symptom, as it is very generally indicative of acute 
enteritis. Gurgling is rare, according to MM. Rilliet and Barthez, in 
ordinary entero-colitis, though very generally present in typhoid fever. 



326 ENTERO-COLITIS. 

Vomiting is very common in young infants, and is generally repeated 
several times a day. In severe and rapid cases it is a very troublesome and 
alarming symptom. In older children it is much less common, and is 
never really violent, except in some of the most acute cases. In them it 
is confined to the first few days of the attack. 

After the diarrhoea is fairly established, young infants are almost always 
either very irritable, peevish, and restless, or weak, languid, and subdued. 
Their slumber is short and disturbed, and generally they sleep much less 
in the twenty-four hours than when in health, unless under the influence 
of anodynes. Older children are generally somewhat restless and irritable, 
but much less so than infants. There is seldom any disorder of the intel- 
ligence, though in acute cases there is sometimes slight delirium or head- 
ache. Fever exists in all acute cases. It is seldom continuous in infants 
except for the first few days, after which it almost always assumes the 
remittent type. It is marked by increased frequency of the pulse, which 
rises to 120 and 140, or in bad cases much higher ; by heat of skin, often 
intense during the exacerbations ) by thirst and diminished appetite ; and 
by dryness and heat of the mouth. In older children the pulse is not 
generally so high as in infants, and in many of the mild cases the fever is 
very slight or there is none at all. In acute cases, however, it is some- 
times continuous and marked by rapid pulse and great heat of skin. 

The tongue is generally normal, though sometimes red on the edges 
and tip in acute cases. It is seldom dry, except during the fever. The 
appetite is almost always lost, and the thirst generally increased, though 
to a less degree than in diseases of the stomach. 

The countenance presents nothing peculiar except that the features are, 
according to MM. Rilliet and Barthez, drawn down towards the inferior 
portion of the face. Emaciation always takes place as the disease pro- 
gresses, and in very severe cases, occurs with the greatest rapidity, so that 
in a very few days the child will be reduced from an appearance of vigor 
and strength, to that of the greatest debility. As this occurs the flesh 
loses its firmness, the skin hangs in folds upon the trunk and limbs and 
is dull and dirty in its tint, the eyes become sunken and surrounded with 
bluish circles, and the whole appearance of the child is that of misery 
and exhaustion. 

In infants it is very common, to meet with erythema of the buttocks 
and thighs, produced by the contact of the acrid stools and urine with 
those parts. This symptom is said by Bouchut to exist in five-sixths of 
the cases. I feel quite sure that it does not exist in so large a proportion 
of those which occur in private practice, though I have met with it in 
some instances. When severe it is generally accompanied by papules 
which ulcerate after a time and form superficial ulcerations upon the skin. 



SYMPTOMS. 327 

These ulcerations sometimes run together and become of considerable 
size and depth. In the form of the disease met with in the children's 
hospitals in Paris, erythema and ulcerations of the heels and internal 
malleoli are also met with, and constitute a serious complication in the 
case. They are said to depend on want of cleanliness, and the rubbing 
together of the feet of the child, unprotected by covering. I have never 
met with them in private practice. 

The duration of the disease is stated by the French writers to be gene- 
rally about fifteen days, at the end of which time convalescence is usually 
established. It may be shorter or longer. According to my own expe- 
rience it is entirely uncertain. Most of the cases that have come under 
my notice have been rather shorter. The disease subsides gradually. The 
number of stools diminishes ; they become less abundant and more con- 
sistent, and return to their natural color and odor; the pain on pressure, 
and the enlargement and tension of the abdomen disappear ; and as this 
occurs, the fever subsides, the appetite returns, the temper improves, and 
the child enters into full convalescence. 

The chronic form of entero-colitis generally follows the acute, though 
it sometimes presents many characteristic features from the first. It 
differs from the acute form chiefly in the absence or the much slighter 
degree of fever and other constitutional symptoms in the early stage. 
The diarrhoea is less abundant and less frequent. At first the child 
retains its spirits and many of the signs of health. But gradually its 
strength fails, the temper becomes irritable, the complexion grows dark, 
sallow, and unhealthy, the skin becomes dry and harsh, and, in conse- 
quence of the emaciation which takes place progressively with the other 
symptoms, hangs in folds around the shrunken extremities, or is drawn 
tightly over the joints and other osseous protuberances. The tongue is 
generally moist and natural, though in some cases red and dry, whilst in 
others it, together with the lips, partakes of the pallor which pervades all 
parts of the body. The abdomen is usually distended and sonorous on 
percussion, and may be painful or not on pressure in different cases, or in 
the same case at different periods of the disease ; its parietes sometimes 
offer no resistance to the touch, so that the intestinal convolutions may be 
readily felt by the hand, or even between the fingers ; and in some cases I 
have seen them so thin and relaxed, though the abdomen was more promi- 
nent than natural, that the outlines of the intestines, and even the peris- 
taltic movement were visible upon the exterior. The appetite generally 
persists in spite of the gravity of the disease, and is sometimes increased. 
The stools, as has been stated, are not so frequent as in the acute form, 
seldom numbering over six or ten in the day and night. They consist of 
the products of an imperfect digestion, and contain not unfrequently the 



328 ENTERO-COLITIS. 

alimentary substances in the state in which they were swallowed, mixed 
with mucus, serum, pus, and sometimes blood. Their consistence varies 
constantly, but they are usually semifluid. Their odor is seldom natural, 
and often extremely offensive. 

The course of the disease is very irregular. Even in the worst and 
most prolonged cases intermissions or remissions occur, so that the child 
will often improve greatly for days or weeks, and then suddenly relapse 
into as bad a condition as ever. In favorable cases these remissions 
become more and more frequent, and the symptoms gradually improve, 
until at length the child is restored to health. In fatal cases death is 
occasioned by the utter deterioration of the general health which finally 
occurs, and the child perishes worn out by long illness, or, as more fre- 
quently happens, some complication arises which hurries on the fatal 
event. Thrush is a frequent complication of chronic entero-colitis, and 
doubtless often hastens the death by the impediment which it occasions to 
the nursing or feeding of the child. Vomiting has almost always occurred 
towards the close of the fatal cases that I have seen, especially in those in 
which extensive thrush was present. 

The duration of this form is of course very uncertain. It may last for 
weeks or months. I have known it to last two and three months in 
several cases, and in two others it lasted with occasional intermissions, in 
one a year, and in the other eighteen months. 

Diagnosis. — The diagnosis of acute entero-colitis is not difficult. 
There is no disease with which it is likely to be confounded. The cha- 
racteristic features of the malady are the diarrhoea and other abdominal 
symptoms, and the absence of signs of other disease. The secondary 
cases are distinguished by the occurrence of the usual symptoms of entero- 
colitis during the progress of the primary malady. 

The chronic form is not likely to be mistaken for any other disorder, 
unless it be the diarrhoea which occurs in tubercular disease, from which 
it is to be distinguished by the presence in the latter of the signs of 
tuberculization of other organs. 

Prognosis. — Acute entero-colitis is always a serious disease in infants. 
The prognosis will depend in great measure on the circumstances under 
which the affection has been developed. It is much more unfavorable in 
a child fed on artificial diet, either wholly or in part, than in one who is 
nursed at a fine breast of milk. It is more unfavorable also in weak and 
delicate than in robust and vigorous children, and in those of poor people, 
who live in crowded unhealthy portions of cities and towns, whose habi- 
tations are small, damp, and ill-ventilated, and whose food is coarse and 
insufficient or improper, than in those placed in more fortunate and more 
healthful hygienic conditions. In hospitals for children it is a very fatal 



TREATMENT. 329 

disorder, owing to the bad hygienic conditions under which the inmates 
are placed. In children, who have passed though the first dentition, the 
prognosis is, as a rule, favorable. The disease is seldom dangerous when 
it occurs as a primary affection, while, as a secondary affection, on the 
contrary, it is much more apt to be serious. 

The unfavorable symptoms are : great frequency of the stools ; collapse ; 
violent vomiting or retching ; and dangerous cerebral symptoms, as coma, 
rigidity of the limbs, paralysis or convulsions. 

Treatment. — The prophylactic treatment of the disease is important. 
It includes attention to diet, dress, exercise, and habitation. It has already 
been stated that one of the most frequent causes of the malady is the 
attempt to bring up the child on artificial diet, and particularly on one of 
an improper kind. It is clear, therefore, that to avoid the disease, it is 
necessary that the child should, if possible, be nursed. If this cannot be 
done, the diet ought to be wisely selected and regulated in all its details 
by the physician. The one which is most proper is evidently that which 
most resembles the natural aliment of the infant. In my hands that 
which has best succeeded is prepared of cow's milk mixed with a small 
quantity of cream, and with water in which a certain proportion of gela- 
tine has been dissolved, in the manner described at page 262. A regimen 
consisting of farinaceous substances prepared with water alone, or milk 
and water alone, has not answered in my hands nearly so well as that 
preparation. It is particularly important that the food should not be 
made too thick, whatever its ingredients may be. For this reason thick 
gruels of all kinds, cracker food as it is called, bread and milk, or thick 
rice and milk, should be absolutely forbidden to children under eight or 
ten months or a year old. Though I have seen some few children thrive 
upon such diet, the great majority suffer from frequent attacks of indi- 
gestion and simple diarrhoea, or are seized with entero-colitis, and either 
die, or make it necessary to change their diet. 

The dress ought to be arranged according to the season. Exercise in 
the open air is of the utmost importance, so much so, indeed, that every 
effort should be made to insure a certain amount of it every day. This 
is, after diet, the most important point in the prophylactic treatment. 

Diet in the attack. — After the disease has made its appearance, the 
diet should be very carefully regulated. This constitutes, in truth, the 
most important point in the treatment. If the child is nursing, it ought 
to be confined entirely to the breast, and should the nurse have a large 
quantity of milk, it must not be allowed to nurse very often, nor very long 
at a time. Should there be the least suspicion that the milk of the nurse is 
unhealthy, it ought to be examined with the microscope, and if found to 
contain colostrum granules, a new nurse must be provided. If the dis- 



330 ENTERO-COLITIS. 

ease comes on shortly after weaning, and persists for several days in spite 
of careful diet and treatment, it is safest to restore the child to the breast. 
"When this cannot be done, we must select that form of artificial diet 
which seems most suitable. The best is, in my opinion, the cow's milk 
prepared with the solution of gelatine in the manner already recom- 
mended, but made very weak for a few days. I have often found it 
necessary, under these circumstances, to add four and even more parts of 
water to the milk, instead of two or equal parts, as is the usual custom. 

In older children the diet, for a few days, ought to consist of nothing 
but barley or arrow-root water ; after which thin preparations of arrow- 
root, rice-flour, sago, tapioca, or wheat flour, made with milk, or milk and 
water, with small quantities of bread, or, if the child refuse such articles, 
panada, or very thin chicken or mutton water may be allowed. The 
quantity of food, whatever it be, ought to be much less than usual, and in 
very severe attacks must be just enough to sustain the strength of the 
child, and no more. This system of diet is to be persevered in until the 
disease is removed, unless the child refuses it absolutely, in which case, 
we may allow pure milk, small quantities of ice cream, a little bread and 
butter, and small portions of chicken or mutton, well cooked, and cut up 
very fine. The return to old habits as the child recovers, or after full con- 
valescence is established, ought to be made carefully and gradually, as 
there is no disease in which relapses are so apt to occur from neglect of 
this precaution. 

Therapeutical Treatment. — I have found a large number of the 
mild cases that have come under my notice, all of which occurred in pri- 
vate practice, to recover under very simple treatment. When the patient 
is an infant at the breast, before the period of dentition, the simple direc- 
tion not to allow it to' nurse as much as usual, the use of a warm bath 
morning and evening if the skin be heated and the child restless and 
fretful, the administration of a small dose of castor oil (half a teaspoonful 
to a teaspoonful), or of spiced syrup of rhubarb in the same quantity, 
with half a drop to a drop of laudanum, followed in one or two days, if 
the disorder continues, by some simple astringent remedy, generally suf- 
fices to effect a cure. When, on the contrary, the case depends on an 
unhealthy or insufficient milk, when the child subsists entirely on arti- 
ficial food, and when the disease coincides with the process of dentition, 
the attack is kept up and aggravated by these causes, and it is more diffi- 
cult to obtain a cure. In the former case the diet is, of course, of all 
importance. In the latter, the gums must be carefully examined, and if 
found to be swelled and inflamed, and the teeth near the surface, they should 
be freely incised. After these matters have been attended to, the kind of 
treatment will depend on the character of the general symptoms and the 









TREATMENT. 331 

violence of the enteritic disorder. When the fever is violent, the dis- 
charges frequent, painful, and mixed with mucus or blood, and the abdo- 
men tumid, tense, and painful to the touch, it is proper to make use of 
depletion in strong and hearty children. When, on the contrary, the 
child is pale and delicate, it is better, it seems to me, to dispense with 
bloodletting in any form. In young infants only leeches need, as a general 
rule, be used. They should be applied over the seat of tenderness, gene- 
rally one of the iliac fossae, in such number as to take about an ounce of 
blood, or in very hearty, sanguine children, two ounces. Dr. Stokes 
{Loc. cit.) is of opinion that it is sometimes necessary to bleed, even in 
infants, as he has seen the disease resist detractions of blood by leeching, 
and yield immediately to venesection. When it is impossible to bleed 
from the arm, he proposes the application of a leech or two to the back of 
the hand or foot, and then to immerse the part in warm water, by which 
method he states that a considerable quantity of blood may be obtained. 
In such instances I have always been able to bleed the child from the 
saphena vein as it runs over the inner malleolus, and would much prefer 
this plan, because we can readily observe the amount of blood that flows, 
which cannot be done when the blood is allowed to flow into water. Dr. 
Stokes recommends a second application of leeches should the first fail to 
relieve the symptoms. In older children we may substitute venesection 
for leeching if we deem it better, taking from two to six ounces of blood, 
according to the age and strength of the patient. During the fever the 
use of warm baths at about 96° or 97° will be found of very great service. 
They should be employed once or twice, or even three times a day, if the 
heat of skin, frequency of the circulation, and restlessness, continue. It 
will often be found very beneficial to envelope the child in a warm 
blanket for half an hour after the bath, as this will sometimes produce 
fine perspiration. 

The internal remedies during" the early stage should consist of one or 
two laxative doses, guarded by small quantities of an opiate j or we may 
administer what is regarded with great favor by most physicians in this 
country, calomel. When the febrile symptoms are strongly marked, I 
believe that this is a very useful remedy in many instances. It is given 
differently by different practitioners. Some prefer one or two large doses, 
while others use it in minute quantities, and repeat it more frequently. 
It seems to me that this ought to depend on the nature of the attack, 
and the age and constitution of the child. In delicate subjects, and 
those within the year, I always prefer to employ small doses, about a 
quarter or sixth of a grain, to be repeated every two hours until a grain 
has been taken, after which I administer a small quantity of castor oil 
or syrup of rhubarb. In stronger and older children, on the contrary, 



332 ENTERO-COLITIS. 

in whom the attack is violent, it is often more useful to give from one to 
four grains in a single dose, and follow it by the laxative in a few hours. 

Dr. J. Cheyne {Loc. cit.) recommends calomel very strongly in the 
treatment of the disease, which, as has been stated, he calls atrophia ab- 
lactatorum. He gave it in doses of half a grain morning and evening, 
continued for a week or ten days, or until the discharges assumed a more 
natural appearance. Dr. Stokes (Loc. cit.) states that the internal reme- 
dies from which he has obtained the most advantage, are a combination of 
a mild mercurial with Dover's powder, and gummy solutions. The mer- 
curial which he employs is the hydrargyrum cum creta. 

I am very much in the habit, in all cases of entero-colitis, of adminis- 
tering opiates in some form. Some writers object to their employment in 
the early stage as injurious. I have never been deterred from using them, 
however, except in cases presenting manifest signs of cerebral irritation in 
connexion with the febrile symptoms. When there has been nothing more 
than irritability, restlessness, and insomnia, when there is evident pain 
during the discharges, and when the latter have been very frequent, I have 
always made use of such remedies without hesitation, and I believe with- 
out injury, but on the contrary, with very great benefit. I am very glad 
to find that Dr. Stokes also employs opium without hesitation. He says 
''it is a remedy that requires caution in its exhibition, but one of great 
utility." It generally lessens the number of discharges, and very often, it 
seems to me, diminishes the heat of skin and frequency of the circulation, by 
allaying the irritability of the nervous system, while at the same time it 
greatly promotes the comfort of the child. I have used it in the form of lauda- 
num or paregoric, given in combination with a laxative early in the case, or 
by enema, and afterwards in that of the Dover's powder or powdered opium, 
mixed with calomel. For a child under six months old half a drop of 
laudanum is enough to give per orem. Of the Dover's powder about a 
sixth or eighth of a grain may be administered mixed with the same quan- 
tity of calomel, to be repeated every two or three hours until three or four 
doses have been taken, or until the child shows some degree of drowsiness 
from the action of the opium, after which it ought to be suspended for six 
or eight hours, and then resumed. If it be desirable to give the opiate by 
enema, about one or two drops may be administered in a teaspoonful of 
thin starch. In cases of older children, the doses must of course be 
larger. For those more than a year old, about two drops of laudanum may 
be given with castor oil or rhubarb ; or a quarter of a grain of Dover's 
powder with the same quantity of calomel, or finally, from two to four 
drops of laudanum by enema. During the acute period of the disease, 
and particularly when the abdomen is distended and painful, warm mush 
poultices, made light and thin, placed between pieces of flannel, and ap- 



TREATMENT. 333 

plied over that region, will be found very useful and soothing remedies ) 
they should be renewed every few hours. 

Generally speaking the acute constitutional symptoms either subside or 
disappear under the above treatment, and very often the diarrhoea also 
ceases and the child recovers. When, however, the diarrhoea persists, it 
is necessary to resort to two other classes of remedies, upon which great 
reliance is placed in the treatment of the affection. These are astringents 
and absorbents, of which the most important are prepared chalk, powdered 
crab's eyes, acetate of lead, rhatany, kino, and catechu. The chalk may 
be used in the form of the officinal Mistura cretae, a teaspoonful of which 
is given after each loose evacuation, or several times a day. When the case 
is severe, the efficacy of this remedy is much increased by the addition of 
tincture of krameria, in the proportion of a drachm to two or three ounces 
of the mixture, of some opiate preparation, or of ten or fifteen drops of the 
aromatic syrup of galls (to be described presently), to each teaspoonful; 
chalk may be used also with great advantage in powder, combined with 
Dover's powder, and sometimes with calomel, or in the form of the Hy- 
drargyrum cum creta, which latter is a favorite prescription of many physi- 
cians, in the dose of from a quarter of a grain to a grain three or four 
times a day. 

The powdered crab's eyes will sometimes arrest cases in which prepared 
chalk fails to produce any effect. It is generally employed in mixture. 
The formula I employ is the following : 

R. — Ocul. cancror. pulv., £i. 

Acacioe, pulv., gii. 

Sacch. alb., ^i. 

Aquas fontis, Aquoe cinnamom., . . . aa^iss. — Misce. 

A teaspoonful to be given four, five, or six times a day. 
M. Bouchut recommends the following prescription of Hufeland's : 

R. — Ocul. cancror. pulv., gr. x. 

Aquas foeniculi, Syrup, rhei, aa^ss. — Misce. 

Give a teaspoonful every hour. 

Acetate of lead has been highly extolled by many writers in the treat- 
ment of the diarrhoeas of children. I have had but little experience in 
its use, and am therefore unable to offer an opinion in regard to the influ- 
ence which it may exert. It may be given in doses of from a sixth to 
an eighth of a grain, alone, or combined with chalk or Dover's powder, 
every two hours. Krameria, 7cino, and catechu may be exhibited alone, 
in the form of infusion or solution, or they may be given in conjunction 



33-i ENTERO-COLITIS. 

with the chalk mixture. I have frequently employed the tincture of 
krameria in the latter way, and believe it adds very much to the efficacy 
of the remedy. About one or two drachms may be added to two ounces 
of the mixture, and the usual dose given. I have used, with much ad- 
vantage, either alone or with chalk or crab's eyes mixture, an aromatic 
syrup of galls, in the dose of from fifteen to forty drops three or four 
times a day, or, when the discharges are very frequent, every two or three 
hours. It is prepared according to the following formula : 

R. — Gallcc opt. pulv., 2;ss. 

Cinnamoin. pulv., gij. 

Zingib. pulv., gss. 

Spts. vini gall, opt., Oss. — Misce. 

Let the ingredients stand in a warm place for two hours, and then burn off the 
brandy, holding some lumps of sugar in the flames. Strain through blotting 
paper. 

Dr. Eberle (Loc. cit., p. 221) highly recommends the root of the 
geranium maculatum. He says it makes an " agreeable and efficient 
astringent," and is less apt to derange the digestive organs, and occasion 
irritation of the mucous membrane of the bowels, than kino. He uses 
it in the form of a decoction made with milk, by boiling an ounce of 
the fresh root in a pint of milk until half is evaporated. The dose is 
from a teaspoonful to a tablespoonful four or five times a day, according 
to the age of the patient. 

The nitrate of silver is highly recommended as a remedy of late years 
by several writers. It is given both internally and by enema. The 
modes of administration will be described in the remarks on the treatment 
of the chronic form of the disease. 

Revulsives are often of much service in the treatment of this, as of 
almost all the diseases of childhood. When there is much restlessness 
and irritability, with heat of the head and trunk, and coolness of the 
extremities, it will be found that mustard pediluvia, or sinapisms to the 
extremities, often allay these symptoms, and greatly comfort the little 
patient. When the abdomen is tense and painful and the discharges 
preceded or accompanied by movements or crying indicative of pain, the 
application of a poultice of mush and mustard from time to time, to be 
followed by a simple mush poultice, sometimes acts very usefully. 

Tonics and stimulants are often necessary in weak and delicate children 
from an early period in the attack, and in those who are stronger, after 
the disease has lasted for some time, and the acute symptoms have ceased, 
and been followed by weakness and exhaustion. The best tonic is, pro- 
bably, sulphate of quinine in doses of from a quarter of a grain to a grain 
three times a day, continued for one, two, or three weeks, if necessary. 



TREATMENT. 335 

Old brandy has answered better in my hands as a stimulant, than wine, 
wine-whey, or any of the tinctures. It may be given to the youngest 
children in doses of five or six drops every two hours, or a teaspoonful 
may be added to a wineglassful of sweetened water, and a teaspoonful 
given whenever the child will take it. I have been obliged, in several 
cases, to continue the use of the brandy for three, four, and five weeks. 
At the time when we are obliged to resort to this class of remedies, it is 
almost always necessary also to pay attention to the improvement of the 
diet. The proportion of milk to water ought to be increased, if it has 
been small heretofore ; and we should employ every means to induce the 
child to take a sufficient quantity without overloading the stomach. At 
this stage small quantities of animal broths are proper, or the child may 
be allowed to suck pieces of juicy meat, or to eat very finely minced meat 
of chicken or mutton. The diet is in fact a most important part of the 
treatment at this period. Dr. Stokes says of it that " many children are 
lost by the practitioner neglecting this point. 

Treatment of chronic entero-colitis. — The management of the 
hygiene of the patient is more important than any other part of the treat- 
ment, in this, as in nearly all the diseases of the digestive organs in chil- 
dren ; for cases will often recover when the diet, drinks, and exercise are 
properly regulated, without the use of any drugs whatever, whereas, most 
assuredly, none or but a very small proportion of them would terminate 
favorably under the best and wisest therapeutical medication, were the 
hygiene of the child entirely neglected. The remarks that have been 
made as to the diet most proper in the acute form will apply here. If 
the child has been weaned only a few weeks before the time at which we 
are consulted, and the case is at all serious, it is better to advise the pro- 
curing of a wet-nurse. I have several times known cases of the disease 
which had resisted the most carefully managed artificial diet and thera- 
peutical treatment, recover in a few days after the child had been restored 
to the breast. It is often, however, impossible to follow this course, 
from the refusal of the parents to obtain a nurse, or of the child to 
take the breast of a stranger, and we are obliged to rest content with 
artificial food. I believe that the kind of diet which suits the largest 
number of children is one of milk. During some four years past, I have 
found the gelatine food already described, to answer better than any that 
I have ever essayed. It ought to be made very light and thin. About 
a scruple of gelatine should be dissolved by boiling in half a pint of 
water. Towards the end of the boiling, a gill of cow's milk, and a tea- 
spoonful of arrow-root made into a paste with cold water, are to be stirred 
into the solution, and from one to two tablespoonfuls of cream added just 
at the termination of the cooking. It is then to be sweetened moderately 



336 ENTERO-COLITIS. 

with white sugar, when it is ready for use. The whole preparation should 
occupy about fifteen minutes. 

When cow's milk, mixed with water alone, or prepared in the manner 
just recommended, evidently disagrees, I have sometimes found cream 
with water alone, or better still, with the solution of gelatine in water, in 
the proportion of one part of cream to five or six of the latter, to suit 
very well. In other cases, very carefully prepared chicken or mutton 
water, given several times a day, or but once, according to the taste and 
fancy of the child, will answer better. It sometimes happens that the 
child will refuse everything that has been mentioned, and yet the pros- 
tration and emaciation are such as to make it essential to procure some 
aliment that it will consent to take. I have, under such circumstances, 
given small portions of bread and butter, or stale sponge cake, with weak 
brandy and water, if the child is old enough to swallow solid food. 
Sometimes it will eat small quantities of meat, and when this has been 
the case, I have not hesitated to allow a chicken bone, with a little meat 
attached to it, or a piece of ham, or better still, a portion of roast beef, 
or of the tender loin of beef-steak, to be held in the hand and sucked ; or 
we may give the white meat of chicken cut up very fine, or torn into the 
finest shreds. Of the latter about a teaspoonful is sufficient for the first 
day, given with a little brandy and water. The quantity can be gradually 
increased afterwards. There is another article which I have sometimes 
given when children have been exhausted for want of food, and when 
they require constant change in order to be tempted to take it. This is 
the yelk of a ha?*d-hoi\ed egg, which has the great advantage of being 
very nutritious if digested, and of not being injurious, should it happen 
to pass into the bowel in the crude state, as it falls into a state of fine 
powder, which is not irritating to that organ. 

The quantity as well as quality of the food is of the utmost importance, 
and should be strictly regulated by the physician, and attended to by the 
mother or nurse. As a general rule the child may be allowed as much 
as it wants of proper food, since the appetite is almost always greatly di- 
minished, and it is not likely therefore, that too much will be taken. If, 
however, there is disposition to nausea or vomiting, or, if the appetite 
remains as good as usual, the quantity must be restricted. The difficulty 
in most cases is to get the patient to take enough, and not to prevent it 
from taking too much, for I have very often ascertained, upon careful in- 
quiry, that the quantity was entirely too small to support the strength of 
the constitution. A hearty child, six months old, fed solely on artificial 
food, will generally take between a pint and a quart of fluid in the twenty- 
four hours, while at a year old, it will take usually fully a quart or more 
of fluid nourishment, besides eating small quantities of solid food. Now, 



TREATMENT. 337 

I have frequently known children laboring under chronic entero-colitis, 
not to take more than one or two gills of food in the day, which is mani- 
festly much too little. When this is the case, therefore, we should always 
endeavor to stimulate the appetite and digestion by means of tonics and 
stimulants, and by causing to be presented to the child such a variety of 
food as may entice it to take a larger quantity than before. 

The therapeutical treatment of the chronic form consists principally in 
the administration of tonics, astringents, and absorbents. Of these the 
most important are the powdered chalk and crab's-eyes, and the different 
vegetable astringents, which have already been noticed in the remarks on 
the acute form. These are to be given in the manner there recommended, 
and it is therefore unnecessary to repeat what has already been said. In 
addition to these there are some remedies which are particularly adapted 
to the chronic form of the disease. Amongst them are nitrate of silver. 
Dr. Eberle (Loc. cit. p. 251) says he has found its internal administration 
to produce the happiest effect in a few instances. His prescription was a 
grain of the nitrate dissolved in an ounce and a half of gum arabic water, 
with the addition of twenty drops of laudanum. The dose was a tea- 
spoonful three times a day. He adds that he has never " known the 
slightest inconvenience to result from the use of this article in chronic 
mucous inflammation of the bowels, when administered in a mucilaginous 
solution and in very small doses. " It has been much used of late years in 
France. MM. Trousseau and Pidoux recommend its internal use in the 
chronic diarrhoeas of children occurring during dentition, after bismuth, 
powdered crab's-eyes, and diet have failed to effect a cure. Their formula 
is as follows : 

R. — Argent, nitrat., gr. ±. 

Aquae distillat., £vi. 

Syrup sarsap., giiss. — Misce. 

To be given in eight or ten doses. 

At the same time they employ an enema composed of a grain of the nitrate 
in three ounces of distilled water. It is highly recommended also in 
these cases by Hirsch of Konigsberg. His formula is as follows : 

R. — Argent, nitrat. cry stall., gr. J. 

Aquge distillat, ^ii. 

Acacias pulv., ^ii. 

Sacch. alb., gii. — Misce. 

A teaspoonful of this mixture to be given every two hours, and an enema, 
consisting of a quarter of a grain of the salt, with mucilage and a little 
opium, to be administered. (Ranking' s Abst., No. vi., p. 61.) I have 

22 



338 ENTERO-COLITIS. 

employed this remedy in the proportion of from half a grain to a grain in 
a gill of water, by injection, morning and evening for several days, with 
very decided benefit, in three cases of diarrhoea following summer-com- 
plaint, in which the stools were frequent, mucous, sometimes streaked 
with blood, and accompanied by tenesmus. Another excellent remedy in 
the chronic diarrhoeas of children, one from which I have sometimes ob- 
tained very satisfactory effects, is the syrup of the nitrate of iron. It 
is given in doses of two or three drops three times a day, in sweetened 
water, at the age of one or two years. Creasote also has been recom- 
mended of late years, and is highly thought of by some practitioners. It 
may be given in doses of from a quarter to half a drop every three or four 
hours, at a year old. Trousseau and Pidoux recommend in this class of 
cases the sub-nitrate of bismuth in the dose of from two to nine grains in 
the twenty-four hours. It may be given in powder, or suspended in syrup 
or milk. Bouchut recommends injection of from ten to twelve grains of 
extract of rhatani/, or six to ten of tannin in about five to seven ounces of 
some vehicle. 

Drs. J. Cheyne, Eberle, Dewees, and Condie, all recommend calomel 
in the treatment of the chronic disease. I am of opinion that it is often 
useful when given in very minute doses (| to T ^ of a grain), in combina- 
tion with Dover's powder, three or four times a day, for three or four 
days, after which I would rather depend on astringents combined with 
opiates, and upon the use of injections of nitrate of silver. I have in 
several cases derived considerable benefit from the use of Hope's camphor 
mixture given in the dose of from five to fifteen drops three or four times 
a day in water. 

It should never be forgotten in the treatment of chronic diarrhoea in 
children, that the most important point of all is the regulation of the diet 
and other hygienic conditions. I am fully convinced that I have seen 
several children saved from death by attention to these points, and by the 
persevering and careful employment of tonics and stimulants. It often 
happens, after the disease has lasted for some weeks or months, that the 
function of the stomach is almost wholly lost. The child either refuses 
food or takes so little that the quantity is evidently insufficient to carry on 
the vital processes, or the greater part of what is taken is rejected by 
vomiting, or lastly, much of it passes off through the bowels, and appears 
in the stools in an undigested state, forming what is called lientery. If 
this condition of things is allowed to continue the emaciation and exhaus- 
tion make rapid progress, and the case must soon terminate fatally. 
Under these circumstances all the ingenuity and skill of the physician are 
required to find means to restore vigor to the digestive function, and to 
recall the appetite of the patient. If the stomach is frequently sick it is 



TREATMENT. 339 

best to abandon all remedies but those which are stimulating and 
strengthening, and especially to forbid all such as are in the smallest de- 
gree nauseous. I would indeed depend entirely on the use of repeated 
doses of the oldest and most delicate brandy that could be found, of which 
from one to two teaspoonfuls may be put into a wineglassful of cold water, 
and the whole given by teaspoonfuls in the twenty-four hours. At the 
same time, the food ought to be chosen with the greatest care, endeavor- 
ing always to please the fancy of the child as much as possible, and it 
should be given in very small quantities often repeated. "While this is 
being done, an occasional dose of anodyne, just enough to tranquillize- 
without stupefying, may be given. If the rectum will retain it, it is better 
to give it by enema. In some cases I have found the aromatic syrup of 
galls given with brandy, to be taken by the child without any difficulty or 
disgust. 

Exercise and exposure to the air are all-important. In some very severe 
and tedious cases, change of residence or travelling has been known to 
effect a cure after all remedies and other means had failed. In one case, 
in this city, which had lasted with but short intervals for two years, I ob- 
tained a perfect cure by persuading the parents to send the child into an 
elevated part of the country in the month of May, where it was kept until 
July, after which it was removed to the seaside until the end of August. 
Nothing was done in the mean time except to regulate the diet most 
carefully, and to keep the child the greater part of the day in the open air. 



ARTICLE III. 



CHOLERA INFANTUM. 



Definition; Synonymes; Frequency. — Cholera infantum can be 
defined only by an enumeration of its characteristic features. These are 
its occurrence in very young children, and in the summer months ; the 
evidences in the early stage of violent irritation and hypersecretion of the 
gastro -intestinal mucous surface, and at a later period- of inflammation, 
ulceration, softening and thickening of the same surface, particularly that 
of the ileum and large intestine : its chief symptoms are vomitiEg and 
purging; fever, generally of a remittent type, varying often with collapses- 
rapid emaciation ; and towards the close, violent cerebral symptoms. 

The common name of the disease is summer-complaint. Though rare 
in Europe, in comparison with its frequency in this country, it is never- 
theless described with sufficient accuracy to point out a clear identity of 



340 CHOLERA INFANTUM. 

the two, by Billard, under the title of follicular enteritis, by Barrier 
under that of apyretic and febrile follicular diacrisis, the latter term being 
taken from Gendrin, and by Copland under that of choleric fever of 
infants. 

It is of all the diseases which prevail amongst children in this country, 
one of the most frequent and important. It appears from Dr. Emerson's 
tables (Am. Journ. Med. Sciences, vol. i. 1827), that from 1807 to 1827, 
a period of twenty years, there was 3576 deaths from cholera under five 
years of age. This is the largest number of deaths, from any one disease, 
given in the table. The next largest item of mortality is under the head of 
convulsions, of which it appears that 3192 died in the same period of life. 
During the five years from 1844 to 1848, inclusive, there occurred in this 
city, 18,599 deaths from all causes under fifteen years of age. Of this 
total, 1611 died of cholera infantum, which is the largest number of 
deaths from any one disease with the exception of convulsions. Of con- 
vulsions there died 1729. After cholera infantum the largest number of 
deaths was caused by marasmus (1060), dropsy of the brain (1041), pneu- 
monia (772), and croup (756). Cholera infantum, therefore, causes nearly 
as many deaths as convulsions during the first fifteen years of life, and 
rather more than twice as many as pneumonia. 

Causes. — The most influential predisposing causes are the heats of 
summer, the impure air and want of ventilation in cities, dentition, im- 
proper diet, early age, and hereditary influence. 

Heat. — That the heats of summer, constitute a powerful predisposing 
cause to the disease is proved by the evidence of almost all writers, and 
by the fact that the disease occurs in its most characteristic and peculiar 
form only during the warmest months of the year. Dr. Lindsly {Am. 
Journ. Med. Sci. vol. xxiv. 1839) gives a table showing the deaths from 
the disease in Washington City, in the five months of June, July, August, 
September, and October, of 1837 and 1838, from which it appears, that 
in the former year there were 4 deaths in June ; 10 in July ; 14 in Au- 
gust ; 3 in September : and 2 in October : in the latter year there were 
2 deaths in June ; 15 in July ; 22 in August ; 14 in September ; and 2 
in October. I regret that the deaths per month from the disease are not 
given in the tables of Dr. Emerson, or in those of Dr. Condie. It is 
universally agreed, however, that the disease is most frequent and fatal 
in the months of July and August, that it is much less so in June and 
September, and that in May and October it is seldom met with. That it 
is not the heat of the season alone, however, is proved by the fact that 
the disease is less frequent and fatal in some of the southern cities of our 
continent than in New York and Philadelphia. It is proved also by the 



CAUSES. 



341 



following table, the materials of which I obtained from the paper of Dr. 
Emerson (Loc. cit.) 



Year. | Me 

i 


an temperature of the three sum- 


Total deaths 


from cholera 


in each 


mer months for each year. 




year. 




1815 


. . . 76° F. . . . 




92 




1819 






.76 ... 


. 


246 




1818 






.74 .... 




196 




1811 






.74 .... 




224 




1817 






.74 .... 




130 




1813 






.72 .... 




173 




1812 






.70 .... 




154 




1814 






.70 .... 




125 




1816 






.70 .... 




87 





The table is imperfect, because I have been obliged to take the whole 
number of deaths from cholera at all ages for each year, and compare 
them with the mean temperature of the three summer months of the 
same years. It is not, however, so imperfect as this would at first view 
make it appear, since the vast majority of the returns under the head of 
cholera in the table of Dr. Emerson, are in fact cases of cholera infantum. 
This is shown by the fact that of 3812 deaths from cholera in the twenty 
years from 1807 to 1827 (including the nine years in the above table), 
only 236 were of persons over five j-ears of age, and of course all the rest 
(3576) were of children, and therefore, cases of cholera infantum. 

The table shows that the number of deaths is not in proportion to the 
mean heat of the season, since in 1815, when the temperature averaged 
76°, there were only 92 deaths, being only five more than in 1816, when 
the mean heat was but 70°. 

It would seem that in order for heat to produce the disease to a great 
extent, it must be combined with the close, impure air of cities. The 
disease prevails most in the low, thickly inhabited, dirty, and badly ven- 
tilated streets and lanes of cities, the atmosphere of which is loaded with 
exhalations and effluvia ; while in the country, at the distance of but a 
few miles from a city in which it prevails extensively, it is comparatively 
very rare, except in children removed from the city. 

Dentition. — I believe this to be a most powerful predisposing cause of 
the disease, and yet it would seem to be less influential than age, for the 
tables of Dr. Emerson show that the disease is about twice as fatal in the 
first year as in the second, though the process of dentition is certainly 
more active and continuous in the second than in the first year. I have 
rarely observed the disease before the beginning of the process of denti- 
tion, and it is certainly very rare after its completion. 

Age, as has just been stated, exerts a strong influence in the production 



CHOLERA INFANTUM. 

of the disease. In the tables of Dr. Emerson, the cases of cholera infan- 
tum and cholera morbus are included under the one head of cholera, but 
as all cases of the disease under five years of age are called cholera infan- 
tum, the want of the distinction does not make the statements less useful 
to us. From them it appears that there were 2122 deaths in the first 
year, 1186 in the second, and only 268 between the second and fifth. 
Between five and ten years, only 52 cases are noted, and these would of 
course be entitled cholera morbus. In the five years from 1844 to 1848, 
inclusive, of 1611 deaths from cholera infantum under 15 years of age, 
969 occurred in the first year of life, 529 in the second, 103 between two 
and five years, and only 10 after that age. 

Sex. — There are no large tables of reference, by which to ascertain 1 the 
exact proportion in which the disease occurs in the opposite sexes. It 
would appear, however, from my own experience to be much more com- 
mon in males than females, since of 77 cases of which I have kept a 
record, 48 occurred in boys, and only 29 in girls. 

Constitution. — The disease is most apt to occur in feeble, delicate 
children, and in those of nervous, irritable temperament. 

Diet. — There can be no doubt that the deprivation of the breast, and the 
use of artificial diet often predisposes to the disease. Indeed, weaning in 
the summer, and the resort to artificial food, often act as an exciting 
cause, the disease making its appearance not unfrequently very soon after 
the change has been made. M. Barrier states that the use of feculent 
substances, often ill cooked or sweetened with too much sugar as food, is 
one of the most frequent causes of the follicular diacrises of young chil- 
dren. This agrees exactly with the opinion of M. Yalleix as to the most 
evident cause of the enteritis and thrush so fatal amongst the children 
of the Foundling's Hospital at Paris. He states it to be improper ali- 
mentation, and particularly one consisting of feculent materials. He adds 
that he has never known a child nourished exclusively at the breast dur- 
ing the early months to have the disease. (Guide du Med. Prat. t. iv. 
p. 60.) The use of too indiscriminate a diet during the second year is 
another frequent cause of the disease. I have several times known it to 
follow the giving a child the smallest quantity of fruit. I am quite satis- 
fied, in fact, that indiscretions in diet are very frequently the exciting 
causes of the disease in children in this city. The recklessness of some 
parents in this country in regard to the diet of their children is, indeed, 
often astounding. One of the worst cases that I saw during the past 
summer occurred in a child who was cutting the last molar teeth of the 
first set, and was occasioned by the eating, on Saturday, of a quantity 
of water-melon at dinner, and of several pears in the afternoon. That 
night the cholera began, and on the following day, in order to cure the 



CAUSES — ANATOMICAL LESIONS. 343 

diarrhoea, the father took the child into the fields, and gave it as many 
blackberries, not over ripe, as it would eat. I have known attacks brought 
on by currants, by peaches, apples, cakes, and all such imprudences. For a 
more detailed account of the influence of diet in the production of dis- 
eases of the intestines in children, the reader is referred to the article on 
entero-colitis. 

Hereditary predisposition. — My own observation leads me to be- 
lieve that the disease is apt to occur in certain families. It would seem 
probable that this peculiarity, if it exists, must depend on the fact that 
the constitutions of some families are particularly disposed to disorders of 
the digestive apparatus. I am acquainted with one family in this city, in 
which eight out of ten children, suffered more or less from the disease. 
Again, of these children, four have grown up, married, and have children. 
Two of these families have each lost a child from the disease ; in a third, 
the two children of the family have been exceedingly ill with it ; while in 
the fourth, some of the children have been sick, though not to the same 
degree. Again, I have attended two children in a family, one not quite 
two years, and the other three months and a half old, who have both been 
very sick with the disease. The elder child was ill the summer before in 
the same way. The mother of these children was herself very ill with 
the disease on several occasions during her infancy, as was also her 
brother. 

Anatomical Lesions; Nature of the Disease. — The best accounts 
of the anatomical lesions observed after cholera infantum will be found 
in Stokes and Bell's Practice (2d edit. vol. i. p. 474-483); in Dr. Wil- 
liam E. Horner's paper (Am. Journ. Med. Sciences, Feb. 1829) ; and 
particularly in Dr. E. HallowelPs article on Endemic Gastro-follicular 
Enteritis, in the same Journal for July, 1847. 

The nature of the lesions depends on the severity of the case, and the 
stage at which the fatal event took place. When death occurs early, the 
only lesions found are unusual development of the mucous follicles or 
glandular apparatus of the stomach and bowels, implicating chiefly the 
isolated glands, and in a smaller number of cases the agminated glands 
or plaques of Peyer. In severer cases, and those which have lasted 
longer, the lesions observed are more important, and consist in inflamma- 
tion and softening of the mucous membrane, and ulceration of the 
follicles, sometimes to a great extent. 

Having already described with considerable minuteness, in the article on 
entero-colitis, the morbid alterations of the follicular apparatus of the gas- 
trointestinal canal, I shall not repeat the description in the present place, 
but merely allude to the alterations by name, referring the reader for a 
more particular account to the former place. The description of the lesions 



344 CHOLERA INFANTUM. 

of cholera infantum which follows, is derived from the analysis of seven- 
teen autopsies of the disease, three of which were made by Professor Hor- 
ner of this city, and fourteen by Dr. Hallowell {Loc. cit.) 

Stomach. — The mucous membrane presented traces of inflammation, in 
the form of arborizations or injection in 6 cases, while in 10 the color was 
noted as pale or natural. Softening to a greater or less extent was noted 
in 10 cases; in 4 the consistence was natural; in 3 it is not mentioned. 
The condition of the mucous crypts is given in 6 : in one not apparent ; 
in one scarcely visible ; in one slightly developed ; in 2 distinct, but not 
much developed ; in one largely developed. 

Small intestine. — Traces of inflammation of the mucous membrane were 
noted in 7 cases, confined generally either to the duodenum or ileum, and 
affecting only a small extent of the bowel ; in 9 the membrane was noted 
as pale ; and in one its appearance is not mentioned. Softening existed in 5 
cases, slight in all ; in 7 the consistence was natural, while in the remainder 
the consistence is not mentioned. The isolated crypts are noted as nu- 
merous and distinct in 2 cases, as slightly developed in 9, as distinct in 
the ileum and not in other parts in 2, and in the duodenum in one ; in 3 
their condition is not mentioned; in 2 only they were slightly ulcerated. 
The agminated glands are stated to have been natural in 6 ; they were 
more developed than usual, and generally reddened, in 6 ; in 5 their condi- 
tion is not given ; they were not ulcerated in any of the cases. 

Large intestine. — The condition of the mucous membrane as to inflam- 
mation is not mentioned in 2 cases; in 9 it is stated to have been more or 
less inflamed throughout ; in 2 the inflammation was confined to the rec- 
tum or the lower part of the colon ; in 4 the inflammation was slight, and 
in 2 of these it existed only around the follicles. The consistence of the 
membrane is not mentioned in 6 ; it was found more or less softened in 9, 
thickened in one, and normal in one. The muciparous crypts are stated 
to have been developed, without any reference to the presence or absence 
of ulcerations in 3 cases ; to have been developed with a few ulcerations 
in 3 ; much developed with many ulcerations in 7 ; and finally to have been 
developed and not ulcerated in 4. The character of the ulcerations is not 
mentioned in all the cases. In some it extended to the sub-mucous tissue, 
and in a few to the muscular. The ulcerations of the crypts are generally 
most marked in the rectum. 

The stomach often contains a good deal of mucus adhering to the lining 
membrane; the small intestines contain orange-colored mucus; while the 
large bowel generally contained mucus adhering to the inner coat, and a 
good deal of thin faecal matter of a grayish color. 

Dr. Hallowell (Loc. cit. p. 49) states that in patients who died during 
the second stage, that is, before the appearance of dangerous cerebral 



LESIONS — NATURE. 345 

symptoms, the lungs presented nothing remarkable beyond a slight en- 
gorgement posteriorly, except in three cases in which the children had had 
measles or hooping-cough, and one in which pleurisy had followed expo- 
sure to the night air. " The peritoneum presented its usual healthy color 
in all the cases observed; the liver was greatly enlarged in but a single 
instance, contrary to the statements of most authors, who affirm this to be 
uniformly the case ; the gall bladder was more or less distended with dark- 
colored bile, staining the finger a deep yellow ; the mesenteric glands were 
not enlarged ; the spleen and kidneys presented nothing remarkable. " In 
regard to the brain he states that in most of the cases the veins of the pia 
mater were more or less distended, and the membrane injected also, but that 
the injection was generally confined to the larger ramifications ; the sub- 
stance of the brain presented injection of the central portion in one, and 
of the central and cortical portions both in another ; there was softening in 
four cases, and little or no effusion into the ventricles. In patients dying in 
the third stage, with stupor, convulsive movements, rigidity or paralysis, 
there were found, in addition to the morbid appearances already described, 
disorganization of the structure of the brain from softening of its tissue. 
The softening, sometimes general, was more frequently confined either to 
the cortical substance, or to the central portions of the brain and cerebel- 
lum. The softening may be such that the brain will readily give way on 
slight pressure, or its substance may be so diffluent as to resemble cream. 
The substance of the brain commonly presents numerous red spots from 
effusion of blood ; the pia mater is more or less injected and its veins much 
distended ; and there is in some cases, but not in all, serous effusion into 
the sub-arachnoid tissue, and lateral ventricles. 

Nature of the Disease. — It was for a long time supposed that cholera 
infantum was peculiar to this country, and widely different from any 
malady reigning amongst children in Europe. Its real nature was very 
imperfectly understood until within a few years, when the researches of 
Dr. Horner showed that it resembled very closely the follicular enteritis 
described by Billard in his work on children. Dr. Hallowell, in his 
recent and valuable paper, which I have so often quoted, gives it the title 
of endemic gastro-follicukr enteritis, and regards it as a disease chiefly 
of the follicular apparatus of the digestive canal. After careful study of 
some of the most important European works upon the diseases of children, 
after close comparison of these descriptions with those given by our own 
authors, and with my own observations, I am led to the conclusion that 
cholera infantum or summer- com plaint is the same disease, with diffe- 
rences of frequency, severity, and fatality, as that described by Billard 
as follicular enteritis ) by Barrier as follicular diacrisis, apyretic, febrile, 
and complicated ; and by the authors of the Bibliotheque du Medecin 



346 CHOLERA INFANTUM. 

Praticien under the title of " enteritis of children," including in that 
term inflammation, softening, diarrhoea, and diacrises. MM. Rilliet and 
Barthez also describe most of the symptoms and anatomical lesions of the 
disease in their chapter on inflammation and softening of the gastro- 
intestinal mucous membrane. Let me state, however, that, while I 
believe cholera infantum to be the same disease in its real nature as 
those just mentioned, I also believe that it differs from them greatly as 
to frequency, severity, fatality, and in the circumstance of a larger por- 
tion of the gastro-intestinal mucous membrane being affected than is 
usual in the milder cases observed in Europe, in which smaller por- 
tions of that membrane are generally implicated. 

From the description of the anatomical lesions already given, it appears 
that the most characteristic and constant morbid alterations are develop- 
ment and ulceration of the follicular apparatus of the stomach and bowels. 
The mucous crypts are stated to have been much developed in the stomach 
only in one instance, and slightly developed in three. They were not 
ulcerated in any. In the small intestine they were more frequently 
affected, having been found numerous and distinct in two cases ; distinct 
in the ileum only in two, and in the duodenum only in one ; and as 
slightly developed in nine. In two only were they slightly ulcerated. Of 
14 cases, therefore, in which their condition in the small intestine is 
mentioned, they were much developed only in two, and ulcerated in the 
same number. In the remaining cases, the alterations were slight, or 
observed only over a small part of the bowel, generally in the ileum or 
duodenum. The agminated glands were natural in 6 cases, more deve- 
loped than usual, and generally reddened in 6, and not ulcerated in any. 
Of 12 cases, therefore, in which their condition is described, they were 
developed in half, and natural in the remainder. In the large intestine 
the crypts are said to have been developed in all the 17 cases. In 10 of 
these they were ulcerated, in 4 not ulcerated, while in the remaining 3 
their condition as to ulceration is not mentioned. To recapitulate : the 
follicles are noted as having been developed in the stomach in three 
cases, as ulcerated in none; in the small intestine they were numerously 
developed in two cases, more slightly so in twelve others, and slightly 
ulcerated in two ; in the large intestine, they were developed in all, and 
of 14 in which their condition as to ulceration is mentioned, that lesion 
was noted in 10. It is clear, therefore, that the follicular disease is most 
constant and extensive in the large intestine, less so in the small bowel, 
and but seldom present in the stomach. 

As to inflammation of the mucous membrane, we found that of 16 
cases in which the state of the membrane was noted in the stomach, that 
lesion was present to greater or less extent, generally very slight, in 6, 



ANATOMICAL LESIONS. 347 

while in 10 the tissue was pale and natural ; of 16 cases in which its 
condition is noted in the small intestines, it was found inflamed, usually 
in the duodenum or ileum only, in 7, while in 9 it was noted as pale ; 
the condition of the mucous membrane of the large intestine as to inflam- 
mation is mentioned in 15 cases, in 9 of which it was more or less inflamed 
throughout, in 2 the inflammation was confined to the rectum, in 4 it 
was slight. Inflammation was observed much the most frequently and 
extensively therefore in the large intestine, only half as frequently in the 
small intestine, and to a much slighter extent, and in a rather smaller 
proportion of cases in the stomach. 

Softening existed to a greater or less extent in the stomach, in 10 out 
of 14 cases in which the condition of the mucous membrane as to that 
lesion was noted ; of 12 cases in which it was sought for in the small 
intestines, it was present in 5, in all slight, while the membrane was 
natural in the other 7 J of 11 cases in which it was noted in the large 
intestine, it was present in 9, absent in 1, while thickening existed in the 
remaining case. Softening existed in the stomach and large intestine in 
about three-fourths of the cases, and in the small intestine in rather less 
than half. 

As to the other abdominal organs, it was ascertained that the liver, 
which has been thought by many authors to play so great a part in the 
pathology of the disease, was much enlarged only in one case ; and that 
the mesenteric glands, spleen, and kidneys were healthy. The brain, on 
the contrary, generally presented some injection of the membranes, and 
in most of the cases which proved fatal in the third stage, there was 
extensive disorganization of its substance from softening. 

For my own part, I am disposed to believe that cholera infantum is a 
disease of the mucous membrane of the alimentary canal, which, begin- 
ning with morbid development of the mucous follicles or crypts, inde- 
pendent of evident inflammation, occasions first supersecretions from those 
organs, and after a time runs into inflammation and its results, ulceration, 
softening, and thickening. That it is not an inflammation in the begin- 
ning is, it seems to me, clear, from the nature of the anatomical lesions, 
and from the facts that the early stage is often unaccompanied by any 
febrile movement whatever, and is not unfrequently attended with dis- 
position to collapse, like that which occurs in the cholera of the adult ; 
but that it becomes an inflammation, after the development of the follicu- 
lar apparatus has lasted a short time, is also, I think, apparent, from the 
nature of the anatomical lesions, and from the circumstance that there is 
always a more or less violent febrile reaction after the first few days. 

Symptoms. — The invasion of cholera infantum is extremely irregular 
in its mode of manifestation. It may be sudden or gradual. When 



348 CHOLERA INFANTUM. 

sudden, the child is attacked with diarrhoea while apparently in good 
health, and either simultaneously, or within a few hours, with more or 
less violent vomiting. I have known a child put to bed early in the 
evening, seemingly well, to wake at ten o'clock, and have twelve large, 
fetid, fluid evacuations before morning, and then pass through a regular 
attack of the disease, lasting ten days. Much more frequently, however, 
the invasion is gradual, and the disease begins with slight diarrhoea, 
which makes its appearance after the child has shown unusual fretfulness, 
irritability, restless sleep, and some loss of appetite for one or two days. 
Most authors agree that the disease generally begins with diarrhoea, which 
after a few days or even longer time, is associated with vomiting. Of 71 
cases that I have seen in which the mode of invasion was noted, it began 
with diarrhoea, and was associated with vomiting, in from two to seven 
days after, in 21 ; in 21 the invasion was sudden, vomiting and purging 
coming on almost simultaneously; in 29 there was no vomiting, or the 
child merely rejected doses of medicine which disgusted it. In sudden 
and violent cases, the vomiting and purging are attended with the usual 
signs of exhaustion ; quick, small pulse ; coolness or coldness, with pale- 
ness of the surface ; altered countenance ; extreme languor, and all the 
signs of severe illness. 

In slight cases there is no fever at first, and the child, though more 
peevish and irritable than usual, can be amused and diverted at times. 
In severer attacks there is often a febrile reaction from the beginning, 
while in very violent cases, the earliest symptoms are those of collapse, 
soon followed generally by intense heat of the head and body, and 
very frequent, tense pulse, which subside after some hours, to give place 
to a more or less complete remission, or to a return of the state of col- 
lapse. 

As the diarrhoea is the most important symptom of the disease, it is 
necessary to trace its characters with as much accuracy as possible. The 
first change in the appearance of the stools is that they become more fre- 
quent, abundant, and fluid, than natural. They retain their homogeneous 
appearance, but change from the dark orange color which they present in 
health, to a lighter yellow, like that of the yolk of egg, and begin to con- 
tain spots of a greenish color. As the case goes on, the green tint gene- 
rally increases, until the whole of the discharge is of that color, so that it 
looks like chopped spinach. This is usually the predominant color of the 
stools after the first few days. There is often mixed with the other materials , 
constituting the discharge small whitish lumps, which consist of undigested 
portions of caseum. Sometimes they contain small quantities of faecal 
matter also. Their consistence varies greatly, according to the stage, 
severity, and duration of the case. At first pasty and mush-like, they be- 



SYMPTOMS. 349 

come after a time semi-fluid, with more consistent portions intermixed, 
the fluid parts running through the napkins and clothes of the child, and 
leaving merely yellowish and greenish, or whitish grumous particles upon 
the latter; while in other cases they are completely serous and leave no 
solid portions whatever upon the napkin. The odor is very characteristic 
in severe cases. It is excessively fetid, so as to render it almost impossible 
to cleanse the child from it, and making it often absolutely necessary to 
open the windows in order to get rid of it. I have known it so bad as to 
produce sickness of stomach in a delicate person. It is impossible to de- 
scribe it except by saying that it is putrefactive in character. This pecu- 
liar odor almost always coincides with copious watery stools, of a dark- 
brown color. In other cases the odor is unpleasant, but much less strongly 
marked, or it may be acid, or again the discharges may be entirely ino- 
dorous. The quantity varies greatly. In severe cases it is much more 
abundant than usual, and is sometimes very large indeed, particularly in 
the early part of the attack. At a later period the quantity is generally 
less, and sometimes amounts to a slight stain upon the napkin only. In 
some of the cases the stools assume a dysenteric character, containing 
mucus mixed with blood in greater or less proportion, in addition to the 
matters above described. 

During the acute stage of the disease the child evidently suffers from 
pain in the bowels. This is shown by fretting, uneasiness, restlessness, 
and crying, for some time previous to a discharge, and by crying and some- 
times violent screaming and tenesmic straining at the moment of the 
evacuation. This is particularly apt to be the case when the discharges 
contain blood or mucus, showing severe disease of the colon or rectum. 

The number of stools in the twenty-four hours is very irregular. As a 
general rule, they will amount to from four or five to six or eight, though 
in severe cases they will run up to fifteen or twenty. I have rarely met 
with more than twenty or twenty-five as the highest number. In one 
fatal case, however, in a child between one and two years old, there were 
between 25 and 30 stools during the second night of the attack, in a 
space of twelve hours. 

The substances vomited consist of the contents of the stomach mixed 
with mucous and bilious matters. The frequency and violence of the 
vomiting differ greatly, according to the severity of the case. Sometimes 
it is very distressing and frequent, so that everything is rejected as soon 
as taken, and with great violence ; at other times there is frequent retch- 
ing and efforts to vomit, though there may be nothing upon the stomach; 
while in other instances again it occurs only two or three times a day. It 
seldom continues to a great extent more than two or three days, after 



350 CHOLERA INFANTUM. 






which it ceases entirely, or recurs only at long intervals, and particularly 
after the child has been allowed to take too much food or drink at one time. 

The disease is almost always accompanied by afebrile movement. The 
period at which this occurs, and its degree, depend on the severity of the 
attack. In bad cases, attended with much diarrhoea and occasional vomit- 
ing, it is almost always considerable, and sometimes violent; whilst in 
those which are milder it seldom appears until some days after the inva- 
sion, and is slight. It is almost always of the remittent type, the exacer- 
bations occurring in the afternoon and evening. In very mild cases there 
may be none, or it may consist merely of slight quickness of pulse, a little 
heat of skin, and unusual restlessness at night. The pulse in mild cases 
retains its regularity, and its volume and tension continue natural. In 
severe cases it is quickened from the first, and as the disease progresses, 
becomes very frequent, rising to 130, 140, 150, or more, and is at the 
same time small, quick, and tense. It becomes feeble, rapid, and some- 
times intermittent, in cases threatening a fatal termination. The skin is 
generally dry and warmer than natural at all times, and becomes hot 
during the exacerbation. The heat is not usually equal over the whole 
surface. In very slight attacks it often affects only the hands and feet, 
while in most of the cases the head and abdomen, particularly the latter, 
are the hottest parts, whilst the extremities, especially the inferior, are 
natural, or cool. In sudden and severe cases, the temperature of the 
whole surface often falls below the natural standard, and the extremities 
are so cold as to require artificial means to keep them warm. Under 
these circumstances the surface is always pale, and there is usually some 
moisture upon it; the pulse is quick and feeble, the expression languid 
and exhausted, and there is indeed every sign of collapse. It not unfre- 
quently happens that the state of collapse alternates with more or less vio- 
lent febrile exacerbations, in which the surface regains its color, the face 
becomes flushed, the skin hot, and the pulse fuller, stronger, and less fre- 
quent. The respiration varies according to the degree of the reaction. It 
rises to 40, 50, or 60. Dr. Hallowell states that when over 30, it is more 
or less interrupted. 

The countenance is scarcely altered in slight cases or in the early stage 
of any. As the disease increases it becomes anxious and distressed, and 
is flushed during the exacerbations, and pale in the remissions. In 
sudden and severe attacks it is exceedingly languid and subdued, pale, 
and contracted ; in protracted cases the features become thin and shrunken, 
the eyes are inanimate and sunken, the skin hangs in folds about the face, 
and the lips are thin, dry, and have a rigid look. The nervous system re- 
veals by various symptoms that it is more or less disturbed in its functions. 
At first the temper only is changed. The child becomes irritable, peevish, 



SYMPTOMS. 351 

aud cross, and cries or frets at the least contradiction or without cause. 
The sleep is restless and disturbed from the first, especially during the 
nights. The child wakes frequently, and almost always with crying ; 
when asleep, its eyes are often but half closed, the brow is contracted and 
frowning; it turns and twists, and moans or cries out as though in pain or 
distress. Towards the termination of fatal cases, drowsiness or stupor are 
very apt to take the place of jactitation. 

The appetite is diminished in mild, and entirely lost in severe cases, 
except in children at the breast, who sometimes nurse with avidity, pro- 
bably from thirst. The thirst is generally intense, especially when the 
febrile reaction is considerable. In some few cases, however, it is not 
present. The mouth is usually warm, and the tongue moist at first, and 
coated with a whitish, yellowish, or brownish-yellow fur. Later in the 
disease the tip and edges become red, and in chronic cases the whole 
tongue often acquires a dry, red, smooth, or polished appearance. In 
those which tend to a fatal termination it often becomes dry and incrusted, 
and is sometimes covered with aphthae. 

The abdomen is rarely tumid or tender to the touch in the beginning, 
except when the disease is very severe, and the invasion sudden. At a 
more advanced stage it almost always becomes tympanitic and tense, and 
sometimes, though not always, when carefully examined, is found painful 
on pressure. It is evident in most cases of any severity, from the draw- 
ing up of the inferior extremities, the twisting and turning of the trunk, 
and the crying of the child, that the evacuations are attended with more 
or less pain. 

Unless the attack be very slight and of short duration, there is always 
manifest emaciation. When the disease is grave the emaciation makes 
rapid progress in a very few days ; and in slow, tedious cases, it is one of 
the most marked symptoms. The skin under these circumstances is dry 
and harsh ; it assumes a wilted appearance, and hangs in folds about the 
neck, and especially over the internal surfaces of the thighs. The ema- 
ciation is sometimes excessive, — as great it seems to me, as in any other 
disease. About the time that the excessive emaciation described takes 
place, there often appears oedema of the feet, and sometimes a bloated 
condition of the face. Simultaneously with the emaciation and oedema, 
aphthae often appear on the tongue, cheeks, gums, roof of the mouth and 
pharynx ; the anus is excoriated by the acrid discharges, and petechiae 
sometimes make their appearance upon the skin, especially the parts on 
which the patient rests. The fatal event is almost always preceded by 
symptoms indicating severe disease of the nervous centres. These are 
drowsiness, passing into stupor and coma ; chewing motion of the under 
jaw, or, as I have several times witnessed, a disposition to rigid contrac- 



352 CHOLERA INFANTUM. 

tion of that part ; rolling of the head from side to side ; and convulsions, 
either general or local, which are followed by rigidity or paralysis of some 
of the limbs, or by irregular automatic movements of different parts of the 
body. 

The duration of cholera infantum is exceedingly uncertain. Dr. 
Eberle (Dis. of Children, p. 285), says it sometimes runs on to a fatal 
termination in five or six hours. The most rapidly fatal case that I have 
met with lasted three days and a half. It often continues for weeks or 
even months. It is not uncommon for a child to be seized with the 
disease in June, and continue more or less sick until the following Octo- 
ber, or November, and in some few instances it continues to have diarrhoea, 
from functional derangement of the bowels, or entero-colitis, the greater 
part of the winter. The attack is very apt to last two or three weeks, 
or until some change in the weather occurs, or the residence of the child 
is changed. 

Diagnosis. — The diagnosis of cholera infantum requires no particular 
elucidation. The season at which it occurs, the age of the patient, the 
concomitance of vomiting and purging, the nature of the evacuations, and 
the course of the affection, render it easy of recognition. I have already 
stated that I believed the disease to be at first, a simple choleric irrita- 
tion of the digestive tube, which rapidly passed into inflammation or 
entero-colitis, if the attack continued a few days. What gives to the 
disorder its peculiar features in this country, in the summer season, is, in 
all probability, the severe and long-continued heat of the weather. 

Prognosis. — It is evident from the remarks made upon the frequency 
of the disease, that cholera infantum is a very serious malady, for it was 
then stated to be, with the exception perhaps of convulsions, the most 
fatal of all the affections of childhood. The prognosis in any particular case, 
however, must be determined by a reference to several different circum- 
stances, of which the most important are : the hygienic conditions in 
which the child is placed ; the age and period of dentition at which the 
disease occurs ; the present state of health ; and the existence or non- 
existence of hereditary predisposition. 

The children of parents who are placed in circumstances of life such as 
to secure the most favorable hygienic conditions ; who can leave the city 
for the country, when such a change is deemed necessary ; who reside in 
large well-ventilated houses in a good quarter of the city ; and who can 
afford the time and money necessary to procure whatever is deemed 
desirable (not to say essential) for the patient, have, doubtless, a vastly 
better chance of recovery than those in opposite conditions. One of the 
most unfavorable circumstances for the child, is the fact of its having 
been weaned at a very early age, or fed on artificial diet from birth. 



PROGNOSIS — TREATMENT. 353 

This, I believe, increases the danger to a very great extent, and yet, even 
here, much may be done by a wise system of dietetic management, 
together with the removal to a proper atmosphere, or change from place 
to place. 

Cases occurring in very young infants, or early in the process of denti- 
tion, are more unfavorable than under opposite circumstances, because of 
the greater mobility of the nervous system in early life, and of the longer 
continuance in action of the predisposing cause, dentition, which tends 
to keep up the disease. Children already in feeble and deteriorated 
health from any cause, are more likely to die than those who are strong 
and well. Lastly, those who belong to families in which the disease has 
frequently prevailed, and especially in which it has proved fatal to other 
children, are in greater danger than where the opposite obtains. 

I have no statistics as to the proportional mortality, beyond the simple 
statement that of 77 well-marked cases under two years of age that I have 
observed in private practice, 5 were fatal. 

The prognosis may be stated in general terms to be unfavorable in 
proportion to the frequency and violence of the vomiting ; the number of 
the stools j the severity of the fever ; and the more or less marked charac- 
ter of the collapse. When the discharges consist merely of serous fluid, 
and they are copious and frequent ) when they consist of small quantities 
of deep green matter mixed with much mucus or with blood ; when accom- 
panied by straining ; when they number from fifteen to twenty -five in the 
day ) when they are very fetid ; and when with these symptoms, the abdo- 
men is tense and tympanitic, the countenance pinched, the expression 
languid, the extremities cool, the pulse rapid and small, and the child 
irritable and restless, or, on the other hand, very still and subdued, the 
prognosis is exceedingly bad. If, after the symptoms just enumerated, 
drowsiness or stupor, and then coma, convulsions, rigidity, or paralysis, 
make their appearance, there is scarcely a hope left. 

The favorable symptoms in a case are : diminution of the fever; equal 
temperature of the whole surface ; cessation of vomiting ; decrease in the 
number of the stools, and a return to their natural color, consistence, and 
odor ; quiet, tranquil sleep ; return of appetite ; and lastly, a restoration 
of the natural temper and gaiety of the child. 

Treatment. — Prophylactic Treatment. — The danger to which teething 
children are exposed from residence in this city during the hot months of 
the year, is now so well understood, that most families who can afford it, 
remove to the country during the warm season, and by this course very 
generally avoid the disease. It is undoubtedly the best plan that can be 
adopted, and very commonly succeeds. When this cannot be done, how- 
ever, the prophylactic treatment consists in the most careful attention to 

23 



354 CHOLERA INFANTUM. 

diet, dress, and exposure to the open air. If possible the child should be 
kept at the breast until it has passed through its second summer, as there 
is but little danger from the disease after that period. If the weaning 
must take place prior to that age, it ought to be accomplished before the 
hot weather begins, as a change from the breast to artificial food during the 
warm season is very apt to bring on the disease. If the child is weaned, 
the diet must be strictly attended to. Up to the age of ten months or a 
year, the food should consist almost wholly of milk containing arrow-root, 
rice, oatmeal, or some farinaceous substance in small quantity. A little 
plain chicken or mutton-water, with rice boiled in it, or a piece of beef or 
chicken to suck, may be given occasionally, but all vegetables and fruits 
should be strictly forbidden. After the age of ten months, some light 
soup and small portions of mutton, chicken, or very tender beef, minced 
very fine, may be given every day in addition to the milk food, which must 
still form the major part of the child's nutriment. Fruit of all kinds, all 
vegetables except rice and potatoes, and the latter are doubtful, ought to 
be carefully avoided until after the hot season has passed entirely away, 
or until the child has its full set of teeth. I have found the food pre- 
pared with gelatine, in the manner described at page 262, to answer better 
than anything else, for a large number of children for whom I have 
prescribed it. 

The dress ought to be arranged according to the heat of the day. It is 
the fashion in this city to keep young children clothed all summer in 
thick flannel jackets and petticoats, and woollen socks. This is certainly 
too much for the hot days which so frequently occur in July, August, and 
early in September, and is often, I believe, very injurious. A light gauze 
flannel shirt is, it seems to me, the only woollen garment that need be 
worn during the warm season. On hot days a child should have only this, 
a muslin petticoat and frock, and the lightest possible socks, or none at all. 
If, as constantly happens in our climate, a cool day comes, there should 
be added to these a light flannel petticoat. 

It is of the utmost importance that children should pass as large a por- 
tion of the day as possible in the open air. In the country this is easily 
managed, and parents almost always contrive to accomplish it; but in a 
city, many people seem to think it of less importance, or their servants 
are occupied with other things, and it is neglected. It is nevertheless a 
matter of the greatest consequence ; the child ought to be kept in the air 
by the nurse a large portion of the day, either in the garden attached to 
the house, if there be one, at the front door, walking the streets, or, better 
still, making short excursions into the neighboring country, taking care, 
however, to avoid the intense heat of the sun during the middle of the 
day. 



TREATMENT. 355 

I believe that with constant and wise attention to these points, viz., diet, 
dress, exposure to the air, and exercise, much may be done towards pre- 
vention of the disease even in families obliged to remain in the city during 
the summer. 

Hygienic treatment. — As soon as a child residing in a city is attacked 
with cholera infantum during the hot season, it ought to be removed, if 
possible, to the country. If this cannot be done, arrangements should be 
made that will allow of its being carried into the air during the cooler parts 
of the day, either in the arms, in a carriage, or by making excursions into 
the neighboring country. If there be extreme exhaustion or frequent 
vomiting, riding every day is too fatiguing, and we must rest satisfied with 
carrying the child through the house, or into the garden on a pillow, 
making it a rule in the former case to have the windows open .as much a3 
possible, to secure a good ventilation. If the patient surmount the vio- 
lence of the attack, but continues to suffer from diarrhoea, loss of appetite, 
and emaciation, and remedies fail, after a trial of some days, to have any 
effect, we ought to insist upon a removal to the country, pointing out to 
the parents, the very great probability of a fatal event, if this step be not 
taken. I believe that the best air for children in this condition is that of 
the sea-side. I have frequently known the most surprising recoveries to 
take place after a removal to the sea-coast, and they will often occur with 
wonderful rapidity. I may state, moreover, my belief that the sea-coast 
is by far the best place to which to take children to pass the summer, for 
the purpose of avoiding the disease. I have rarely known cases to origi- 
nate there, though this happens occasionally in the country. 

The diet must be strictly and attentively regulated day by day. If the 
child is still at the breast, it ought, if the nurse have enough, to be con- 
fined entirely to it. Nothing else should be given except cold water from 
time to time to slake thirst. If the child has been recently weaned, the 
wisest course to pursue is to procure a wet-nurse at once. When, on the 
contrary, it is fed wholly or in part upon artificial food, the regulation of 
the diet is decidedly the most important point in the treatment. The 
choice of food must depend in some measure upon previous habits. 
It may be stated, however, in general terms, that the food ought to consist 
at least in part of milk or cream, a wholly farinaceous diet, as I have so 
often said, being, as a rule, unsuitable and injurious to the digestive 
organs. The diet that I prefer is the gelatine food already described, 
made with a small proportion of milk ; for, though an infant may be able 
to digest, when in good health, pure cow's milk, or milk weakened with a 
third or half water, it will often fail to do so when the digestive power of 
the stomach is diminished by disease. I would therefore recommend only 
a fourth, fifth, or even sixth part of milk, with a very small quantity of 



356 CHOLERA INFANTUM. 

cream, to be added to the solution of gelatine. To this, arrow-root may be 
added, in the proportion of a teaspoonful to a pint of the fluid. If, as some- 
times happens, the child cannot digest milk, we may try cream one part, 
to water four, five, or six parts ; or we may allow a little chicken, or mut- 
ton water, in which a small quantity of rice has been boiled, and after- 
wards strained out ; or rennet whey may be given, and when the child is 
very weak, wine-whey with the addition of arrow-root water. As the dis- 
ease subsides, or when the appetite is very poor, the patient may be allowed, 
with advantage, a piece of ham, chicken, or under-done beef to suck. 
During the height of the attack it is important to regulate as well the 
quantity as the quality of the food. This ought to be much less than in 
health, even should there be a disposition to take as much, which is seldom 
the case. When vomiting is frequent, and especially when it is obstinate, 
I have often found it necessary and useful to restrict the quantity to a 
very small amount, for instance, a tablespoonful, or even a teaspoonful, to 
be given only every half hour or twenty minutes, until the sickness ceases, 
after which it may be gradually increased. In severe cases it is sometimes 
well to allow nothing but gum water, or barley or arrow-root water, given 
in the manner just mentioned, for one or two days, taking care always 
not to let the child become too much exhausted for want of nourish- 
ment. 

Therapeutical Treatment. — It is evident, I think, from the character of 
the anatomical lesions, and from the nature of the disease, that most cases 
begin as a simple irritation of the secretory apparatus of the gastrointes- 
tinal mucous membrane, independent of evident inflammation. If this 
view be correct, the treatment in the early stage should be simple and cal- 
culated to avoid any increase of the already existing irritation. When the 
symptoms are those of simple diarrhoea, in which the stools are merely a 
little more frequent, abundant, and fluid than natural; when there is little 
or no vomiting ; and when the constitutional symptoms consist of slight 
heat of skin and restlessness at night, with some languor and unusual irri- 
tability, I have found that lancing the gums if they required it, careful 
regulation of the diet as to quality and quantity, the use of the tepid bath 
morning and evening, or sponging with tepid spirit and water, and the 
administration internally of half a teaspoonful or a teaspoonful of spiced 
syrup of rhubarb, with one or two drops of laudanum on the first day, to 
be followed by a similar dose, or the use of some astringent remedy on the 
second day, will often remove the disease without its becoming aggravated. 
When, however, the attack progresses, and vomiting, with signs of entero- 
colitis and fever, make their appearance, the ease requires other treatment 
than that just mentioned. 

Attention to the state of the gums is undoubtedly a most important 



TREATMENT. 357 

point in the management of cholera infantum. It often happens that a 
child will have an attack of the disease whenever the gum over an advanc- 
ing tooth becomes very much swelled and tense, which shows the intimate 
connexion that exists in many cases between the process of dentition and 
the disease. The gums therefore, must always be examined, and if found 
to be prominent over any of the teeth, and at the same time hard, shining, 
and hot, they should be freely incised. I am convinced that this opera- 
tion is often of great service in relieving irritability and insomnia, and 
also in rendering the disease more tractable to remedies, by removing a 
very important predisposing cause. 

Baths. — The use of the warm and tepid bath, and of sponging with 
water and spirit, are important and beneficial elements in the treatment. 
In slight attacks, the tepid bath, used twice a day, has proved of great 
service in my hands. When there is severe fever with excessive jactitation, 
the warm bath should be resorted to twice or three times a day ; or we 
may employ the affusion bath with water at 98°, containing vinegar, in the 
manner to be recommended in the treatment of scarlatina. It is a good 
plan, if the skin is very dry and hot, to lift the child immediately 
from the bath into a blanket or cotton sheet, which has been moderately 
warmed, when, by wrapping it up. we may often obtain a perspiration, 
followed by calm sleep. If the child be weak and exhausted by a tedious 
or violent attack, a warm bath to which half a pint or a pint of whiskey 
has been added, will be found a very soothing and refreshing application. 
When the use of the bath alarms or annoys the child so much as to pro- 
duce violent agitation, it is better to abandon it for a time, and substitute 
sponging with warm or tepid whiskey and water, two or three times a 
day. In cases of extreme exhaustion, also, sponging is to be preferred to 
baths. 

Purgatives. — The careful employment of purgatives in the disease 
is recommended by many writers. The motives for their use are diffe- 
rently stated by different authorities : some prescribe them with the 
view of emptying the bowels of vicious secretions, or of accumulations, 
others to stimulate the liver to greater activity, and some, especially the 
French writers on diarrhoea enteritis and follicular diacrisis, to modify 
the mode of action of the secretory apparatus of the intestinal tube. M. 
Legendre (Loc. cit. p. 672) says : " We agree entirely, therefore, with M. 
Grendrin, who regards emetics and purgatives as the most efficacious 
remedies in the treatment of the intestinal diacrisis.'' For my own part 
I have generally employed them with care at some period of the disease, 
but feel convinced that they are capable of doing great injury when too 
freely or incautiously used. I believe that the proper moment for their 
administration is at the beginning of the attack, when we have reason to 



358 CHOLERA INFANTUM. 

suppose that the bowels may contain the products of an imperfect diges- 
tion, or an accumulation of vicious secretions, or, whenever, in the course of 
the disorder, the stools are observed to be partially consistent, dark-colored, 
and very offensive. I think that in the latter condition of things they are 
very useful, particularly when preceded by several minute doses of calomel 
repeated every hour. When, on the contrary, the stools are copious and 
watery, of a deep-green color, mixed with a great deal of mucus, and 
accompanied with tenesmus and crying, I believe that they tend to aggra- 
vate the symptoms. The only purgatives which I venture to employ are 
rhubarb, magnesia, castor oil, or calomel. Of these, I prefer in the 
majority of cases, rhubarb, in the form of the spiced syrup; of this a 
teaspoonful, or if the dose is to be repeated the same day ; half a teaspoon- 
ful, guarded with half a drop or a drop of laudanum, is a proper quantity. 
If it be desirable to give a more speedy and active laxative, castor oil is 
preferable. A teaspoonful of this is as much, I think, as ought to be 
given in a single dose, and very often half the quantity is fully enough. 
When there are signs of acidity of the digestive organs, magnesia is the 
best purgative. From a quarter to half a teaspoonful is enough for a dose. 
Calomel is highly recommended both as a purgative and alterative by 
many different authors. The dose varies between a quarter or half-grain, 
and two or three grains, repeated every two, three, or four hours, until 
its effect on the bowels becomes manifest. My own opinion is that such 
doses are too large for young children, except in acute inflammatory 
diseases, and that they are apt to aggravate the existing irritation of the 
digestive mucous membrane. Moreover, it seems to me that such doses 
of a remedy acknowledged to be a powerful sedative, cannot be proper in a 
disease which frequently occasions symptoms of great exhaustion, or even 
collapse. From personal experience, therefore, I am disposed to believe 
that it is better not to use calomel in purgative doses as a general rule, 
but to exhibit it in very small quantities, and follow it by some laxative, 
as, for instance, syrup of rhubarb or castor oil. The manner in which I 
prescribe it is to give a tenth or sixth of a grain, with a quarter or sixth 
of a grain of Dover's powder, every hour or two hours, until half a grain 
or a grain has been taken, after which I prescribe a small quantity of 
rhubarb or castor oil, and pursue the same treatment the next day, or the 
day but one after. Employed in this way, I have seen it of great service 
in correcting the discharges when they have been of a dark brown color 
and very offensive, and sometimes when green and mucous. Dewees 
(Dis. of Children, p. 421) says he has never found " temporizing reme- 
dies, as the alkalies, the absorbents, or external irritants, of the smallest 
service, we, therefore, never employ them." As soon as the stomach is 
tranquillized, he resorts to minute doses of calomel, giving as the average 



TREATMENT. 359 

quantity a quarter of a grain every hour, until the bowels are decidedly 
operated upon, which " may be known, by the stools being more copious, 
less frequent, and of a dark green color, with a tenacious slime of the 
same or nearly the same tint of color." After this the doses are given 
less frequently; once in two, three, or four hours. A larger dose of 
calomel, two or three grains, may sometimes be exhibited with advantage 
when the constitutional symptoms are violent, and particularly when there 
are signs of severe cerebral irritation early in the attack. I have seldom 
found it useful to continue the calomel, in whatever dose employed, more 
than two or three days. 

Antiphlogistics. — Dewees remarks that if there is "much fever, with 
great gastric distress, we have found the most decided advantage from 
bleeding, or the application of leeches over the region of the stomach ; or 
if there be much cerebral determination, we bleed from the arm, or draw 
blood from the temples by leeches." He recommends caution however 
in the use of depletion, and says he never employs it during the decline 
of the disease. Eberle says that when the abdomen is tumid, tense, and 
tender to the touch, and the pulse frequent, contracted, and quick, deple- 
tion ought to be resorted to either by venesection or by leeches to the epi- 
gastrium. He thinks this ought to be done promptly and efficiently when 
the above symptoms are present. Dr. Condie recommends leeches to the 
epigastrium when there is increased heat of skin, when the patient appears 
to suffer much pain, and when the abdomen is tumid and tender to the 
touch. Leeches to the epigastrium are recommended also by Dr. Wood 
(Pract. of Med. vol. i. p. 677), when there is much tenderness of the 
abdomen, and the patient is not much exhausted. The same author 
advises a resort to local and general depletion, carried as far as circum- 
stances will permit, when symptoms of meningeal inflammation occur 
early in the disease. M. Bouchut (Loc. cit.) opposes the employment of 
antiphlogistics in entero-colitis, except in some rare cases attended with 
strong febrile reaction and turgescence of the general capillary system. 
The authors of the Bibliotheque du Med. Prat. (t. v. p. 674), state that 
antiphlogistics are now almost entirely abandoned in the treatment of the 
enteritis and diacrises of children. Dr. Hallowell (Loc. cit.) speaks 
strongly of the importance of the antiphlogistic treatment, " instead of 
the purgative plan usually pursued and with such fatal results." He re- 
commends venesection, or when the state of the pulse contraindicates it, 
leeches or cups to the abdomen. 

I have seldom made use of depletion in the treatment of the disease, 
having been deterred from it in severe cases by the disposition to exhaus- 
tion and collapse, and in mild cases, by the belief that it was unnecessary. 
The cerebral symptoms which occur in the early stage, and which seldom 



360 CHOLERA INFANTUM. 

consist of more than great excitement, restlessness, and irritability, have 
usually subsided without difficulty under the use of the warm or tepid 
bath, revulsives, or mild laxative doses; whilst those which occur to- 
wards the close of the fatal cases, and for which I formerly employed 
leeching on several occasions, without any benefit whatever, are, I am 
now satisfied, much more likely to be aggravated than ameliorated by de- 
pletion of any kind. In fact, I now have no doubt that the cerebral 
symptoms which occur in the latter stages of cholera infantum are of the 
same nature exactly as those described by M. Barrier (Loc. cit. t. ii. p. 
56-7), as occurring in the follicular diacrises, of which he says, after 
stating that they more or less simulate meningitis: "On the whole, we 
are of opinion, from our researches, that they rarely depend upon intra- 
cranial inflammation ; that, under other circumstances, especially when a 
slow and chronic mucous fever has occasioned great general debility, the 
serous diathesis, or anasarca, they may be the result of serous effusion 
into the ventricles or cavity of the arachnoid, and that they then constitute 
true hydrocephalus, a malady in which inflammation plays but a mini- 
mum part in the production of the phenomena. The only condition in 
which hydrocephalic or phlegmasial irritation seems to us at all common, 
is that in which there exists difficult dentition capable of determining a 
true and active sanguine congestion towards the head, and this coinci- 
dence of difficult dentition with gastro-intestinal diacrises is not rare, as 
is well known. But the cases are still more numerous in which the en- 
cephalic symptoms are of a purely nervous nature, not to be attributed to 
inflammation or active dropsy, and leaving no traces in the nervous cen- 
tres when these are examined after death/' If this view of the nature 
of the cerebral symptoms attendant upon the gastro-intestinal affections 
of children be correct, it would lead us to the opinion that antiphlogistics 
can seldom be necessary in their treatment, and such, as I have already 
stated, is the conclusion at which I have arrived from experience. When, 
however they are accompanied by hot and flushed skin, with strong and 
active pulse, it would no doubt be proper to direct the application of 
leeches to the temples or behind the ears, of cold to the head, a blister to 
the nucha, revulsives to the extremities, and to make use of laxatives. 

Revulsives are recommended by Parrish, Dewees, and Eberle, when the 
temperature of the surface is unequal ; for the relief of troublesome vomit- 
ing ; and when there is decided determination of blood to the brain. De- 
wees and Eberle recommend the application of a blister over the epigas- 
trium when there is troublesome vomiting, and upon the extremities when 
these are cold, and when the cerebral symptoms are threatening. Dewees 
remarks that they usually promote perspiration, and adds : "It is a fact 



TREATMENT. 361 

not sufficiently known, that -without vesication, in certain conditions of 
the skin, diaphoresis will not take place." Eberle recommends the ap- 
plication of a blister behind the ears or to the back of the neck in the 
treatment of the disease, and says he has been much more successful 
since the adoption of this plan, than previously. He was led to the em- 
ployment of this method by the example of Dr. Parrish, who began it 
from observing that infants who have the eruption behind the ears, so 
common during dentition, generally enjoy "an exemption from those 
daDgerous disorders incident to this critical period of life.'' 

I have commonly resorted to revulsives under the circumstances above 
mentioned, and have almost always used mustard in the form of sinapisms, 
poultices, or foot-baths. When vomiting is very troublesome, a mustard 
plaster, or better still, a poultice made of two parts of Indian meal and 
one of mustard, applied over the abdomen for fifteen or thirty minutes, is 
a most excellent remedy. This may be repeated with great propriety in 
two hours, if necessary. Sometimes a spice plaster, made of different 
kinds of aromatics, as powdered cloves cinnamon and capsicum, half an 
ounce each, with enough flour and wine to make a poultice, and applied 
hot over the epigastrium ; or one made of cloves, nutmeg, ginger, and 
hot wine or water, and used in the same way, answers an excellent pur- 
pose under the circumstances referred to. When the extremities are cold, 
and the child weak and exhausted, the use of sinapisms, hot foot-baths, 
or frictions with dry mustard, have proved very useful in my hands. I 
have never employed blisters except in cases attended with threatening 
cerebral symptoms, and then I have usually directed a small one to be 
applied to the nucha, taking care not to leave it in place more than one 
and a half or two hours, lest it might produce sloughing. I have never, 
however, known them to prove of essential service, except in the early 
stages of the disease. When the cerebral symptoms come on late in the 
attack, and consist of convulsions., rigidity, or paralysis, I believe blisters 
rarely or never do any good. 

Opiates. — Eberle, in speaking of opiates, says that the use of opium is, 
in general, highly improper in the early stage. With this I entirely 
agree, so long as there is severe fever and cerebral irritation ; but when 
the stools are frequent, the child very uneasy and restless, and the dis- 
charges accompanied with pain, and especially when there is but little 
fever, while a disposition to coolness of the skin and exhaustion are 
manifest, from the violent onset of the disease, I believe that minute 
doses of opium, either in connexion with a laxative, with calomel, or by 
enema, prove a very useful and powerful curative means. I almost always 
resort to opium under these circumstances, making use of laudanum or 
paregoric, if it be given with syrup of rhubarb or castor oil ; of Dover's 



362 CHOLERA INFANTUM. 

powder, if with calomel; or of laudanum, if by injection. The dose of 
the opiate ought to be carefully graduated to the age of the child and the 
severity of the attack, being guided under the latter circumstances espe- 
cially, by the degree of pain and restlessness. It ought to be such as to 
tranquilize, rather than produce deep or long-continued sleep. 

After the febrile stage of the disease has passed away, and particularly 
when there are signs of subacute entero-colitis, or dysentery, opium is, in 
my opinion, one of the most important remedies at our command. It 
may be used either per orem, or by injection, and should be administered 
twice or three times a day. From one to three drops of laudanum may 
be given by injection under the age of one year; or half a drop to two 
drops per orem, or from ten to twenty drops of paregoric in the same 
manner. A very excellent form of opiate to employ is the Dover's 
powder, alone or combined with chalk, or acetate of lead. Of this I 
generally give from a quarter to half a grain three or four times a day. 
M. Bouchut remarks {Loc. cit. p. 229) that opiates are very much 
depended upon by the Germans, and quotes Hufeland as asserting that 
opium is " of all remedies the one which promises the greatest cer- 
tainty." 

Astringents. — Both Dewees and Eberle oppose the use of this class of 
remedies in the early stage as injurious. After the symptoms of reaction 
have somewhat subsided, and the remedies proper in the early stages have 
been made use of, nearly all writers coincide in recommending astringents 
for the purpose of diminishing the action of the secretory apparatus of 
the bowel, and of controlling the inordinate peristaltic action which is 
one of the chief causes of the frequent discharges. M. Legendre, who, 
as we have already seen, prefers the employment of emetics and purga- 
tives in the early stage of the follicular diacrises, recommends, in cases 
in which these fail to give relief, the use of absorbents, astringents, and 
sedatives. M. Bouchut {Loc. cit.) also makes use of astringents and 
tonics in the treatment of the diarrhoeas of young children. I am in the 
constant habit of resorting to them in acute and violent cases, so soon as 
I am convinced that the laxatives administered at the beginning have had 
some action upon the bowels, and after or without the use of calomel ; 
whilst in subacute cases, in which diarrhoea is the most important symp- 
tom, and in most of the chronic cases, they, with diet and carefully regu- 
lated hygiene, form the basis of the treatment I have been in the habit 
of employing. 

The most important of those in general use are chalk, powdered crabs' 
eyes, nut-galls, kino, catechu, rhatany, and acetate of lead. The best 
are the chalk and crabs' eyes, in combination with the astringent tinctures 
or with opiates, and the aromatic syrup of galls. Their modes of preparation 



TREATMENT. 363 

and doses are given under the head of entero-colitis, to which place the 
reader is referred. The following is a formula which I have often made 
use of with much benefit in restraining the frequency of the discharges : 

R. — Tinct. krameriae, gii. 

Tinct. opii, gtt. xii. 

Syrup zingiberis, . . 3i. 

Aquae fluvial., 3 xiv - — ML 

A teaspoonful four, five, or six times a day. 



Another very useful one is the following : 

It. — Tinct. kraineriae vel catechu, . . . 

Tinct. opii, 

Mist, cretae, 

Aquae fluvial., 

A teaspoonful from four, to six or eight times a day 



£ii. 

gtt. xii. 
^iss. 
3x.— M. 



The acetate of lead is recommended by Eberle, Chapman, and Condie. 
It may be given iu doses of from a quarter of a grain to a grain every 
two or three hours. Dr. Condie recommends it in doses of a grain, in 
combination with calomel, chalk, and ipecacuanha, to be repeated every 
three hours. I have used the sugar of lead only in dysenteric cases, and 
am therefore unable to give an opinion as to its efficacy in cholera in- 
fantum. We may also use with much benefit the nitrate of silver, both 
internally and by enema, or the subnitrate of bismuth, or injections of 
extract of rhatany or tannin. The doses and modes of administration of 
these preparations have already been fully detailed in the remarks on the 
treatment of chronic entero-colitis. 

Tonics and Stimulants. — It is often necessary to resort to these reme- 
dies in violent and in chronic cases of cholera infantum. When, for in- 
stance, in a sudden and severe attack, the patient falls into the state of 
collapse which so often accompanies the disease, the use of stimulants 
becomes absolutely necessary. The one I prefer before all others is fine 
old brandy. Of this a teaspoonful may be put into a wineglassful or half 
a tumblerful of water, and the child made to drink of it from time to time ; 
or, from ten to twenty drops may be given every hour or two hours. If 
brandy cannot be obtained, or if it be strong and bad, old rum may be 
substituted, or very fine wine, or wine-whey, either alone or mixed with 
arrow-root water. In chronic cases also, when the child is weak and lan- 
guid, inattentive, and without appetite from long illness; when the stomach 
seems to have lost in great part its digestive power, so that the patient 
not only refuses food, but often rejects by vomiting, in an undigested state, 



364 CHOLERA INFANTUM. 






what was taken hours before, stimulants and tonics will be found of the 
greatest service. In some such cases I have been obliged to use a certain 
quantity of brandy three or four times a day for several days or even weeks 
in succession. There need be no fear of resorting to these remedies in 
cases marked by the above symptoms. I have never known them to do 
harm, and believe them to be often indispensable. Of the tonics, the best 
is probably quinine, in the dose of a quarter or half a grain three or four 
times a day, suspended in syrup. 

A very excellent stimulant is the aromatic spirits of hartshorn, which may 
be given in doses of five or six drops every two or three hours. Eberle 
recommends tincture of cinnamon, in doses of fifteen or twenty drops in 
some mucilaginous fluid, every four hours. 

One of the most troublesome symptoms of the disease is vomiting, 
which is sometimes so obstinate and frequent as to be extremely ex- 
hausting. It is very important to relieve it on account of the prostration 
by which it is accompanied, and to enable us to administer the remedies 
proper for the diarrhoea. Dewees says that there is nothing so certain, or 
so prompt in allaying the sickness, "as an iajection of a gill of warm 
water, in which is dissolved a large teaspoonful of common salt ; this is 
for a child of a year old and upward, proportionably less for younger.' ' 
He says it must be given no matter how frequent may be the discharges* 
I have never resorted to this plan, having always succeeded with other 
remedies which seemed less likely to irritate the bowel, and which, there- 
fore, appeared to me preferable. I have generally found a hot mush 
poultice, a mustard poultice, or a warm spice plaster applied upon the 
abdomen, and the administration internally of iced brandy and water by 
teaspoonfuls, of lime-water and milk, of minute doses of calomel, or of 
very small doses of some opiate, with the direction that the drinks and 
food shall be given only by the teaspoonful or tablespoonful for twelve 
hours, successful in arresting the vomiting however violent it might be. 
During the last four years I have found, on some occasions, that even the 
smallest doses of calomel appeared only to increase the irritation of the 
stomach. Under these circumstances I have succeeded in arresting the 
vomiting by withdrawing all milk food, even the breast, from the patient, 
for a space of six or twelve hours, and allowing no other nourishment than 
one or two teaspoonfuls of thin chicken tea to be given once in the half hour; 
while I gave as the remedy a few doses of from six to ten drops of solution 
of morphia every hour, with a teaspoonful occasionally of iced water slightly 
acidulated with the aromatic sulphuric acid. When the patient has been 
much exhausted a teaspoonful or two of weak brandy and water thoroughly 
iced, has been given alternately with the chicken tea. Eberle recom- 
mends, under these circumstances, the application of a blister over the 



DYSENTERY. 365 

epigastrium; while Dr. Condie speaks very highly of the following 
formula : 

R. — Aquse purre, . . . . , jfi. 

Acetat. plumb., ......... gr. v. 

Acid, acetat. impur., "njjv. 

Sacch. alb. pur., ^iii. — M. 

A teaspoonful to be given every hour or two, until the vomiting is suspended. 



ARTICLE IV. 

DYSENTERY. 

It seems to me unnecessary, after the long article on entero-colitis, to 
make more than a few remarks on dysentery, which almost always exists 
in children in combination with inflammation of the small intestine, con- 
stituting the disease already treated of under the title of entero-colitis. 

Dysentery is characterized by frequent evacuations, attended with more 
or less severe pain and straining, and consisting of mucoso-sanguinolent or 
sanguineous substances. 

The causes of dysentery seem to be but little understood, beyond the 
mere facts that it occurs as an endemic in some regions of country, and as 
an epidemic over large districts. It is frequent, also, as a sporadic 
disease, and in this form seems to depend upon the same causes as those 
already cited as productive of entero-colitis. Like cholera infantum, it 
appears to be more common in boj-s than girls, since of 39 cases of which 
I have kept notes, in which the sex is mentioned, 27 occurred in boys, and 
only 12 in girls. It is most frequent in the second and third years of 
life. Of 38 cases in which the age was noted, one occurred in the first 
year of life, 15 in the second, 7 in the third, 3 in the fourth, 3 in the 
fifth, 1 in the sixth, 3 in the seventh, 3 in the eighth, and only 2 from the 
eighth to the end of the eleventh year. It may be either idiopathic or 
secondary. As a secondary affection it is most apt to follow measles and 
variola. I have often known dysenteric stools to occur in the course of 
cholera infantum, and in a considerable number of cases such as I have 
described under the title of entero-colitis. 

The anatomical lesions are confined chiefly to the large intestine, and 
are the same as those described under the head of entero-colitis, except 
that they are of a somewhat graver character. The mucous membrane is 
commonly found thickened, swelled, red, and softened ; the sub-mucous 
tissue sometimes presents ecchymosed points; the follicles are often 
diseased, their orifices being enlarged, and ulcerated, as described under 
entero-colitis. In grave cases, particularly those occurring under an epidemic 



366 DYSENTERY. 

influence, there are usually more or less extensive ulcerations, which may 
implicate only the mucous, or extend to the muscular or even peritoneal 
coat. In such instances, pseudo-membranes also are often formed, some- 
times in large quantity, and often covering the ulcerations. The intestine 
contains sanguinolent mucus, sometimes a brownish or greenish material, 
which is evidently the result of a gangrenous condition of the mucous 
membrane, pus, and lastly false membranes. In some rare cases, perfora- 
tion has been known to take place. 

Symptoms. — The symptoms are much the same as those already de- 
scribed as existing in entero-colitis, excepting that the local symptoms are 
more severe, and the presence of blood in the stools nearly constant. The 
disease often begins as a diarrhoea. The stools at first contain feculent 
materials, but after a time become very thin, small in quantity, and consist 
chiefly of mucus mixed with blood. The blood may be black and in con- 
siderable quantity, or of a dark rosy red color, or like the washings of 
flesh ; it is mixed with greenish or yellowish substances, whitish mucus, 
fragments of false membrane, or purulent fluid. In young children there 
is evidently pain, from the restlessness, moving of the limbs, and crying 
about the time of the evacuations, while in those who are older, there is 
true tenesmus, like that observed in adults, and severe pain in the anus. 
The number of stools varies according to the severity of the case. There 
may be only four, eight, or ten in the day, or many more. I have quite fre- 
quently known as many as 30 and 40 to be voided in the twenty-four 
hours, and in fatal cases, the dejections sometimes number three or four 
in an hour, while between the discharges the child often suffers under 
violent and painful tenesmus. 

The abdomen is generally distended, tympanitic, warmer than natural, 
and painful. 

In mild cases there is usually no fever, or very little, while in severe 
attacks, there is high fever during the first few days, marked by frequent 
pulse, hot dry skin, followed, after a time, unless a favorable change takes 
place, by coolness of the surface, contraction of the countenance, hollow, 
sunken expression of the eye, rapid emaciation, and death. 

It is useless to give a longer detail of the symptoms, as they are the 
same as those already described in the article on entero-colitis. 

The diagnosis presents no difficulties. The frequency of the discharges, 
the pain in the course of the colon and in the anus, the tenesmus, and the 
character of the evacuations, all make the disease easy of recognition. 

The prognosis is favorable in mild cases, unattended with much fever, 
or very frequent discharges. When, on the contrary, there is violent 
fever in the beginning, followed by disposition to coolness and collapse ; 
when the stools are exceedingly frequent, and attended with violent pain 
and almost constant straining; and when they consist of nothing but 



TREATMENT. 367 

mucus, mixed with considerable quantities of blood, or with pus or false 
membranes, the prognosis is very unfavorable. Of 36 cases, the termina- 
tion of which I have recorded, 4 proved fatal. 

Treatment. — The treatment of dysentery in children is often very 
unsatisfactory. The mere variety of the remedies recommended by dif- 
ferent writers and practitioners marks the uncertainty of the effects ob- 
tained from drugs. Mild cases so generally get well under any treatment 
that all methods have had their supporters and advocates, while grave 
cases, and especially those occurring under the influence of severe epidemic 
visitations, are so difficult of treatment, and often so little under the evi- 
dent control of medical means, as to leave the careful observer in great 
doubt as to what he ought to set down as the clear result of his own inter- 
ference in the case, and what as the result of the efforts of nature to cure 
the disease. 

Mild cases of the disease, in which the fever is not very high, the num- 
ber of stools not great, and the pain and distress moderate, require little 
else than rest in bed, a light and unirritating diet, and the use of opium 
in small quantities either internally or by injection. When there is any 
reason to suspect the presence of unwholesome food in the stomach, or of 
unhealthy secretions in the intestines, it is well to give in the beginning 
small doses of some mild cathartic. The one generally preferred is castor 
oil, which may be given either simple, in the dose of a small teaspoonful 
containing one or two drops of laudanum, or in the form of emulsion. The 
latter is the mode of employing it usually chosen. A drachm of oil should 
be rubbed up with a scruple of gum, a little sugar, from two to eight drops 
of laudanum according to the age of the child, and seven drachms of some 
aromatic water. The dose is a teaspoonful every three or four hours. If 
the case continue to improve under the emulsion, it may be continued for 
a couple of days, but should the stools become more and more frequent, 
and the pain and tenesmus increase, it ought to be suspended after one or 
two days, and laudanum enemata with or without the internal use of 
absorbents and astringents substituted. The injections ought to consist 
of four or five drops of laudanum at two years of age, and of ten drops at five 
or six years, suspended in from half an ounce to an ounce of some muci- 
lage or thin farinaceous fluid. The injections may be given twice or three 
times a day if necessary, or they may be made use of only at night, while 
small doses of Dover's powders are administered every three or four hours 
through the day. 

The diet in these cases ought to consist of arrow-root, sago, tapioca, or 
some such food, made into thin pap with milk and water; and the quantity 
allowed ought to be moderate. Kest in bed, in the cradle, or in the lap, 
is very important. The child ought not to be allowed to run about, or 
use much exertion of any kind. 



368 DYSENTERY. 

Where the pain is severe and the fever rather high, and where there is 
a good deal of soreness in the abdomen, depletion may with propriety be 
resorted to, but always with much moderation and prudence. A few leeches 
applied around the margin of the anus, or to the surface of the abdomen, 
often prove of great service in relieving pain and tenesmus. An occa- 
sional warm bath is frequently very soothing and useful. 

In very severe cases of dysentery the treatment is, as above stated, diffi- 
cult and uncertain, owing to the dangerous character of the disease, and 
to the fact that so many different methods have been recommended by dif- 
ferent writers. 

In the early stage of a severe case, whilst the febrile reaction is high 
and the strength of the patient still unsubdued, depletion by leeches in 
young children and by venesection in older ones, is strongly approved of 
by many able practitioners. For my own part I have not resorted to it 
as a general rule, from the fact that I have so often found the strength of 
the child to fail rapidly under the disease itself. In a few cases, however, 
leeching around the anus has been followed by manifest benefit. The 
remedies most commonly depended upon are castor oil, in emulsion with 
laudanum, mercury, sugar of lead, opium, nitrate of silver, spirits of 
turpentine, and astringents. The castor oil emulsion, prepared as men- 
tioned above, is useful in the early part of the attack, but ceases to be so, 
according to my experience, after the first twenty-four or forty-eight hours. 
From mercury I have not myself obtained any very positive benefit, 
though, in combination with opium and ipecacuanha in small doses, it is 
much thought of by many excellent authorities. The only remedy which 
is used by all, though it is rarely given alone, is opium, and the very fact 
that it is so universally employed points it out as one of the most reliable 
and valuable means we have at our command. It is certainly the one upon 
which I most depend myself. It may be given either alone or in connexion 
with other substances. Where injections can be retained it is best given 
in that way. About five drops of laudanum at two years of age, or ten 
drops at four or five years, may be given in a tablespoonful of any bland vehi- 
cle every four hours. When the rectum rejects the enema as soon as used, the 
opium should be given per orem, in the form of laudanum or solution of mor- 
phia, or in that of Dover's powder. Opium is almost always employed in con- 
nexion with some other remedy, and particularly with calomel or acetate 
of lead. The dose of calomel is from a sixth to half a grain, or, as used 
by some practitioners, a grain, with a twelfth of a grain of opium, or half a 
grain or a grain of Dover's powder, every three or four hours, for children 
two or three years of age. The acetate of lead is more relied upon, and 
has probably higher testimony in its favor than calomel. I have myself 
obtained excellent effects from it in some instances. The dose is from half 
a grain to a grain every two or three hours at two and three years of age. 



TREATMENT. 369 

There are two other remedies not yet mentioned, which have been of 
more positive efficacy in my own practice than any others, with the excep- 
tion of opium. These are the nitrate of silver and the solution of the 
nitrate of iron. The former I have used both internally and by injection, 
the latter only by injection. For an account of the mode in which 
nitrate of silver is employed by different authorities, the reader is re- 
ferred to the remarks on chronic entero-colitis. I have employed 
this remedy in 14 cases of dysentery. These were all severe attacks, 
and some of them most violent. Of the 14 cases, three died. The 
remedy was given by the mouth alone in 7 cases, by injection alone 
in 5, and by the mouth and by injection both in 2. It has proved most 
beneficial in its effects, in my hands, when given by the mouth, though 
its influence over the disease has always been less immediate than when 
used by injection, but then they have been more permanent. The dose 
in which I have used it has varied with the age of the child, and with the 
severity of the symptoms. For children two years old I have usually 
employed from a quarter to half a grain, and for those of five or six years 
or upwards, a grain, dissolved in two ounces of a vehicle consisting of an 
ounce each of syrup of gum arabic and distilled water. The dose is a 
teaspoonful every two or three hours. It is well, as a general rule, to add 
from four to sixteen drops of laudanum, according to the age of the sub- 
ject, to the mixture. For use by injection I have commonly employed for 
each enema half a grain for young children, and two grains for older ones, 
dissolved in four ounces of distilled water. On a few occasions I have 
made use of two grains dissolved in two ounces for each injection. The 
injections are to be repeated twice or three times a day. After the nitrate 
of silver enema has come away, it is a good plan to throw into the bowel 
a laudanum and starch injection. 

I have made use of the solution of nitrate of iron, to which allusion 
was made above, only as an injection in acute dysentery. I have em- 
ployed it in eight cases, and am quite sure that it was of essential service 
in six, while in two it appeared to irritate, probably because the quantity 
given was too large. My mode of applying it is to mix from ten to 
twelve drops in four ounces of tepid water for each injection. The injec- 
tions were given twice or three times a day, and they were followed, as 
soon as they had returned, by a laudanum injection. On two occasions, 
the nitrate of iron injection has remained in the bowel for several hours 
before being rejected, and has thus restrained for that time the stools, which 
had previously been very frequent, and attended with much tenesmus. 

The hygienic management of dysentery should be precisely the same 
as that which was suggested as proper for entero-colitis. 

24 



CLASS III. 

DISEASES OF THE NERVOUS SYSTEM. 
GENERAL REMARKS. 

It is a very common opinion both in and out of the medical profession, 
that this class of diseases occasions a much larger number of deaths in 
childhood than any other. Indeed, many persons suppose that, be the 
primary disease what it may, nearly all children who die, die as it is said 
by the brain. It appears, however, from an examination of the bills of 
mortality for this city, that this opinion is not well founded. During the 
five years from 1844 to 1848 inclusive, the number of deaths from dis- 
eases of the nervous system was less than from diseases of the digestive 
system, and though larger than those from diseases of the respiratory 
organs, not so much so as /the popular notion would seem to warrant. 
The number of deaths from diseases of the nervous system was 3,970 ; 
from diseases of the digestive system, 4,204; and from affections of 
the respiratory system, 3,376. M. Barrier, whose observations were 
made at the Children's Hospital in Paris, says {Log. cit. t. i. p. 35) that, 
setting aside cases in which the nervous symptoms were probably only 
sympathetic of some other coincident disease, the cerebro-spinal affections 
were few in number in comparison with those of the thorax, abdomen, and 
senses, including amongst the latter the eruptive fevers. He states (Loc. 
cit. p. 34) that affections of the thorax constituted two-fifths of all the 
cases of disease, those of the abdomen and senses each one-fifth, and of 
the nervous centres only a tenth. M. Barrier, after combating the opinion 
so generally entertained, that disorders of the nervous system cause the 
death of the greater part of the subjects who die before puberty, says {Loc. 
cit. t. ii. p. 233) that there is only one circumstance that in part justifies 
this opinion, which he opposes "not as false, but as exaggerated," and 
this is, that the affections alluded to are almost always of a dangerous 
character, that they are beyond the resources of art, and that they furnish 
a very considerable relative mortality. He says that according to his 
experience the mortality in diseases of the cerebro-spinal system has been 
as sixty-eight in a hundred, whilst in those of the thorax, senses (in- 



TUBERCULAR MENINGITIS. 371 

eluding the skin), and abdomen, it was respectively as forty-eight, forty, 
and thirty-two in a hundred. 

Before beginning the consideration of the particular diseases of this 
class, I am desirous of stating that I shall be compelled, on account of my 
limited space, to devote attention chiefly to those which are most impor- 
tant from their frequency or severity, avoiding or merely alluding to those 
which are of less consequence. 

I shall divide the whole subject into two classes, the first of which will 
contain all the diseases attended with, and dependent upon, some appreci- 
able alteration of the nervous centres, while the second will contain those 
in which no such alteration exists. Amongst those belonging to the former 
division, I shall treat of tubercular meningitis first as the most important, 
then of simple meningitis, of cerebral congestion and hemorrhage, and lastly 
of acute hydrocephalus, by which I mean serous effusions in the brain in- 
dependent of tubercular disease. Encephalitis or cerebritis, and induration 
and softening of the brain are of such rare occurrence in children as dis- 
tinct and essential affections, that it is not necessary to treat of them sepa- 
rately. Amongst the diseases belonging to the second class I shall treat 
of several different convulsive affections, to wit, general convulsions or 
eclampsia, laryngismus stridulus or spasm of the glottis, idiopathic con- 
traction with rigidity, and lastly of chorea. 



CHAPTER I. 

DISEASES OF THE NERVOUS SYSTEM ATTENDED WITH APPRECIABLE 
ANATOMICAL ALTERATIONS. 

ARTICLE I. 

TUBERCULAR MENINGITIS. 

Definition ; Symptoms ; Frequency. — This disease is characterized 
by violent cerebral symptoms, dependent upon the existence of tubercular 
granulations in the pia mater, as the essential anatomical lesion ; and in 
the great majority of cases, by coincident inflammation of that membrane, 
by softening of the central parts of the brain, by effusions of serum into 
the ventricles, and in many instances by tubercular deposits in other organs. 
Until within a few years tubercular meningitis, simple acute meningitis 
independent of tuberculization, and simple dropsical effusion within the 



372 TUBERCULAR MENINGITIS. 

cavity of the cranium independent of inflammation, have been confounded 
together under the single term of hydrocephalus or water on the brain. It 
has been shown of late, however, it seems to me, by the researches of the 
French observers, that a large majority of the cases of acute hydrocephalus 
of authors are, in fact, cases of tubercular meningitis. I am well aware that 
many of the English writers have not adopted this view of the pathology 
of these diseases, but nevertheless, it appears to me, that the observations 
of MM. Gi-uersant, Gerhard and Rufz, Barrier, Rilliet and Barthez, Bou- 
chut, and several others, have sufficiently proved that such is the fact. 

The term hydrocephalus ought to be, and indeed is at present by 
many, restricted to the disease whose essential condition is the existence 
of serum in some part of the brain independently of acute inflammation. 
It is scarcely necessary to state that the popular term " water on the brain," 
is applied to almost every acute case in children in which dangerous or 
fatal cerebral symptoms are present. 

There can be no doubt that this disease is one of rather frequent occur- 
rence, though I am acquainted with no statistics excepting those given by 
M. Barrier {Loc. cit. t. i. p. 84, 36), which will enable us to form any- 
thing like an accurate idea upon this point. That author states that, 
during the period in which his observations were carried on at the Chil- 
dren's Hospital in Paris, there occurred 576 medical cases of all kinds. 
In this number there were only ten cases of tubercular meningitis, whilst 
there were 88 of pneumonia, 48 of pleurisy, 24 of typhoid fever, 48 of 
measles, &c. &c, showing the first-named disease to be much less frequent 
than many other affections. We may also form some idea of its frequency 
in proportion to other diseases, by a reference to the work of MM. Rilliet 
and Barthez, who report 33 cases of tubercular meningitis, against some- 
what over 245 of pneumonia, 174 of bronchitis, 111 of typhoid fever, 167 
of measles, and 87 of scarlet fever. I am of opinion that it is not of 
frequent occurrence amongst the easier classes of this city, since I have 
met with only seventeen cases in private practice in the course of eleven 
years. From what I have been told by other practitioners, however, it 
seems probable that it is much more common amongst the destitute classes, 
and particularly the blacks, who crowd the southern parts of the city, and 
who suffer to a great extent from tubercular and scrofulous diseases. It 
is impossible to obtain accurate information in regard to the frequency of 
the disease in this city, in comparison with other affections of the brain, 
from a reference to the bills of mortality, because of the fact that all or 
nearly all those affections are returned under the single title of dropsy of 
the brain. It may be stated, however, that, during the five years from 
1844 to 1848, inclusive, there occurred in this city 1041 deaths from hy- 
drocephalus or dropsy under fifteen years of age, whilst during the same 



CAUSES — LESIONS. 373 

years there were 850 deaths from pneumonia, and 616 from bronchitis. 
Some of the cases returned under the title of dropsy of the brain were 
no doubt pure hydrocephalus, acute or chronic, others simple meningitis, 
and others no doubt different diseases in which cerebral symptoms occur- 
red at the fatal temination ; but a large number must have been instances 
of tubercular meningitis. 

Predisposing Causes. — MM. Rilliet and Barthez state that the dis. 
ease is most frequent between the ages of 6 and 10 years, and then, in 
order of frequency, between 3 and 5, 11 and 15, and lastly 1 and 2 years. 
The influence of sex has not been determined. It is clearly shown, I 
think, that a feeble constitution and the lymphatic temperament act as pre- 
disposing causes, though on the other hand, it is also apparent, that it is 
not at all rare for children seemingly with every mark of robust and vigor- 
ous health, to be suddenly attacked with the disease. It is propagated 
also by hereditary influence. It is not uncommon for several children in 
a family to die of tubercular meningitis. Under these circumstances, it 
has generally been ascertained that the parents, or some of the immediate 
relations, have either died of tuberculous or scrofulous disease, or shown 
unequivocal signs of that diathesis. It may follow other diseases, and 
has been observed particularly after measles and other febrile diseases, 
and after the suppression of eruptions. 

M. Barrier {Loc. cit. t. ii. p. 379) explains, and I think with good show 
of reason, the causes of the disposition on the part of the tubercular dia- 
thesis in children to localize itself in the brain, as well as the dispropor- 
tionate violence and extent of the inflammatory action in proportion to 
the degree of the tubercular lesion, by the physiological conditions of 
the nervous system in early life, which are those of great functional 
energy, and nutritive activity. 

As to the exciting causes, nothing positive is known. The disease has 
been supposed to be brought into action by falls and blows upon the head, 
by violent moral emotions, and by exposure to the sun. These causes, 
however, are all of doubtful influence. 

Anatomical Lesions. — The tubercles, which constitute the essential 
anatomical element of the disease, are very rarely found in the cavity of 
the arachnoid membrane, but almost invariably beneath that tissue, or in 
the pia mater. They generally exist either as yellow granulations or as 
miliary tubercles; gray granulations are rare. They may exist sepa- 
rately or together in the same individual. The isolated yellow granula- 
tions constitute the most frequent form of tubercle found in the meninges. 
They may commonly be seen through the arachnoid, scattered about in the 
shape of small, yellow, flattened bodies, from two to four-fifths of a line in 



374 TUBERCULAR MENINGITIS. 

diameter, scarcely resisting under the finger. When the pia mater is 
torn off from the surface of the brain, other granulations which had been 
buried in the anfractuosities, come into view. These are rounded in shape, 
differing from those lying on the surface of the convolutions, which, as we 
have seen, are flattened from the pressure of the arachnoid. The size of 
the granulations varies very much. They are sometimes so small, and so 
closely resemble in color the surrounding parts, that it requires a careful 
search to detect them. They vary greatly also in number, existing some- 
times in the greatest quantity throughout the pia mater, whilst in other 
cases it is difficult to find more than one or two on each hemisphere. 
They are found on all parts of the surface of the brain, on the convex and 
internal surfaces of the hemispheres, on the lateral and middle portions of 
the base, in the fissures of Sylvius, and on the cerebellum. They are 
more numerous, according to Rilliet and Barthez, on the convex surface 
of the hemispheres, than at the base, but this is contrary to what has been 
asserted by most other authors, who assert positively they are more 
frequently met with on the cerebellum than upon the hemispheres. 
Wherever found, they may be either isolated at some distance from each 
other, or collected together into groups of greater or less extent. 

Miliary tubercles, which are not unfrequently met with, vary much in 
size, number, and arrangement. They vary in size from that of a hemp- 
seed to that of a pigeon's egg. Generally there are one, two, or three, 
about as large as a pea or small nut ; if more numerous, there are seldom 
over fifteen or twenty, when they are usually about the size of a hemp- 
seed. Generally isolated, they are sometimes united into irregular masses, 
containing portions of altered pia mater. They are more frequent on the 
convex surface than at the base of the hemispheres, and on the left than 
right hemisphere. They are rarely found in the fissures of Sylvius, or on 
the cerebellum. As the tubercle enlarges it becomes strongly united to 
the membranes, and these latter, owing to the presence of the tumor, be- 
come attached to the dura mater. Internally, the tubercle forms a depres- 
sion in the substance of the brain, into which it sinks deeper and deeper, 
until it is almost surrounded, preserving, however, its connexion with the 
pia mater. 

I shall next consider the lesions which coexist with tubercles of the 
meninges. The most important of these are inflammation of the mem- 
branes, and serous effusion into the ventricles. The chief seat of inflam- 
mation, as of the tubercular deposition, is the pia mater; the arachnoid 
membrane being, as a general rule, affected only to a slight extent. That 
membrane sometimes, however, contains a very small quantity of clear or 
turbid serum in its cavity. Its surface is often dry and viscid, and in 



ANATOMICAL LESIONS. 375 

some instances its whole tissue is opaque and thickened. But it is chiefly 
in the pia mater that are found the evidences of severe inflammation. In 
order to detect these changes, it is necessary to examine the membrane, 
not merely upon the surface of the brain, but to tear it off, so as to bring 
into view the portions which dip in between the convolutions, and which 
often exhibit the greatest amount of morbid alteration. The inflamma- 
tory lesions vary between mere vascular injection, infiltration with clear, 
turbid, or gelatinous liquid, and the most abundant suppuration. When 
the inflammation has gone beyond mere sanguine injection, it is marked 
by infiltration of the membrane with turbid, whitish, or sanguinolent 
serum, with pus, which may be liquid or concrete, or with whitish coagu- 
lated lymph. These products are most abundant at the base of the brain, 
about the peduncles of the cerebrum, and in the fissures of Sylvius ; on the 
convexity of the hemisphere they are more abundant on a line with the 
anfractuosities than on the summits of the convolutions. The pia mater, 
which in a healthy brain can be readily detached from the surface of that 
organ, becomes, in cases of meningitis, particularly those which are vio- 
lent, more or less adherent, so that in tearing it off, portions of the cere- 
bral substance come with it. The proper tissue of the membrane is 
thickened and indurated, the degree of thickening depending on the 
amount of infiltration. 

After the changes in the pia mater, the most important anatomical fea- 
ture is effusion within the ventricles. This was formerly thought to be 
the essential lesion of the disease, but recent researches have shown that 
it is absent in some instances which have followed in all respects the 
ordinary course of the malady. According to M. Barrier, effusion cannot 
be supposed to exist unless the ventricles contain from one and a half to 
two ounces of fluid, whilst Rilliet and Barthez assert that the normal 
quantity is a few grammes (about a drachm). The quantity is very 
variable ; sometimes there are only a few drops or a teaspoonful, while in 
other instances it amounts to three ounces and a half, or much more. It 
may be so large as greatly to distend the ventricles, rupture the soft com- 
missure of the thalami, and even the septum lucidum, diminish considera- 
bly the thickness of the hemispheres, and flatten the convolutions against 
each other. In such cases the effusion passes through the membrane of 
the ventricle, and infiltrates into and softens the substance of the brain, so 
that the latter becomes almost of the consistence of thick cream. The 
characters of the fluid vary in different cases. It is white, perfectly limpid 
and transparent, or it may be turbid, either from being secreted in that 
condition, or from holding in suspension albuminous or purulent flocculi, 
or portions of the broken-down walls of the cavity. In some rare instances 



376 TUBERCULAR MENINGITIS. 

it is sero-sanguinolent. Rilliet and Barthez remark that the effusion 
which coincides with tubercular meningitis is different from that which 
accompanies tubercles of the brain. In the former it takes place rapidly, 
is turbid, exists in smaller quantity, and constitutes acute hydroce- 
phalus. In the latter it is secreted slowly and in considerable quantity, 
dilates the walls of the cranium, and constitutes chronic hydrocephalus. 

The brain itself presents various morbid alterations. The whole organ 
often seems enlarged, so that the dura mater appears distended, and when 
the latter is cut into, the cerebral substance protrudes in the form of a 
hernia. At the same time the convolutions are observed to be pressed 
agaiust each other, and the anfractuosities seem to have disappeared. 
The compression of the brain depends either upon the distending action of 
the ventricular effusion, or upon sanguine turgescence of the organ. In 
most cases, but not in all, there is evident congestion of the cerebral sub- 
stance, shown by a more or less abundant dotted redness, and sometimes by 
a general rosy tint of the medullary, and vivid redness of the cortical por- 
tion. Softening of the substance of the brain is of common occurrence in 
connexion with the other lesions. I have already spoken of the softening 
of the walls of the ventricles when there is much effusion, and which 
appears to result from the macerating influence of the fluid. I have also 
referred, very cursorily, to the softening which exists under the inflamed 
portions of the membranes, and which occasions adhesion of the pia mater 
to the brain beneath. In the latter cases the softening may be either 
red or white, and does not penetrate more than a line, and often less, in 
depth. 

In addition to the changes already described, it is quite common to 
meet with tubercles of the brain itself, having no connexion with the 
meninges. These are found in various parts of the organ, and differ 
greatly in size, varying generally between that of a millet-seed and hazel- 
nut, but reaching sometimes the volume of a pigeon or hen's egg, or even 
that of half the fist. 

I have a few words to say in regard to the lesions of other organs. It 
is undoubtedly true that in the vast majority of cases tubercles are found 
in other parts of the body. Of all the cases of tubercular disease ob- 
served by Rilliet and Barthez, amounting to 312, in only one was the 
deposit confined to the meninges. {Luc. cit., t. iii., note, page 49.) M. 
Valleix (Guide du Med. Prat. t. ix. p. 196, 197) states, that in all the 
cases, without exception, of tuberculization of the meninges in adults, 
tubercles exist also in the lungs, and that the same is true, in the vast 
majority of cases, in regard to children. The organs in which the deposit 
is most apt to exist are the bronchial ganglions, lungs, mesenteric glands, 
pleura, and peritoneum. 



LESIONS — SYMPTOMS. 377 

Another very frequent lesion is softening of the stomach. This may 
affect only the mucous or all the coats, so that a slight degree of force 
will suffice to tear the organ. Dr. Gerhard (Am. Journ. Med. Sci., vol. 
xiv., 1834) states, that lesions of the stomach existed in six of the ten 
cases detailed by him, and in four-fifths of others not detailed. 

Before quitting this subject, I would call the attention of the reader to 
the fact mentioned by M. Yalleix (Loc. cit. t. ix. p. 214), that all the 
symptoms about to be described as constituting the disease under con- 
sideration, with the exception of paralysis, may depend on simple tuber- 
culosis of the meninges. Several cases have been cited, in fact, in which 
the only lesion found after death consisted of granulations in the pia 
mater. No traces of inflammation were observed. It is clear, therefore, 
that the evidences of the disease, or symptoms, depend not merely on in- 
flammation caused by the tubercular deposits, but on the presence of that 
morbid production. The paralysis, which is one of the important symp- 
toms, is thought to depend chiefly on softening of the substance of the 
brain. The author referred to states that it occupies the side opposite 
that in which the change exists. 

On the other hand, it also happens that children die with all the symp- 
toms of the disease, and after death, very few or no granulations are 
found to account for the inflammatory changes existing in the head, but 
the tuberculous product is found in other organs of the body, thus esta- 
blishing, I think, the true nature of the case. 

Symptoms ; Course ; Duration. — The disease has been divided by 
authors into different stages, founded on the predominance of certain 
symptoms at particular periods of its course. 

These divisions are all imperfect and unsatisfactory, because the disease 
is in fact a continuous one, and for this reason some writers have avoided 
attempting any classification of the symptoms. It seems to me, however, 
that we can obtain a more faithful picture of the disorder by adopting 
the division made by M. Yalleix, which, though arbitrary and imperfect, 
because of the want of a natural line of demarcation, seems warranted by 
the very great differences in the character of the symptoms at an early and 
late period of the affection. I shall therefore describe first the invasion 
of the malady, and then two stages or periods of the symptoms after the 
disease is confirmed. 

The invasion may be slow and tedious, or very sudden. In the majority 
of cases it is sudden, the child when attacked being apparently in good 
health; while in a smaller number it occurs during the course of tuber- 
cular disease of other parts of the body, or after various symptoms of 
disordered health have existed for a considerable length of time. Whether 



378 TUBERCULAR MENINGITIS. 

slow or rapid, it is marked by three important symptoms, headache, vomit- 
ing, and constipation, to which is added in a large majority of the cases, 
slight acceleration of the circulation. At the same time the intelligence 
of the child remains perfect, the strength is not greatly diminished, the 
ajyctite is not entirely lost, and the thirst is moderate. These symptoms 
usually last but two or three days before others make their appearance, 
showing that the attack is confirmed. In some few instance, however, 
they last, with irregular intermissions, for several weeks. In one case, 
in a girl six years of age, that came under my notice, the invasion was 
preceded during three months by occasional cough, and irregular attacks 
of fever, by progressive emaciation, paleness, languor alternating with 
extreme irritability, disinclination to take exercise, and during the latter 
part of the time by partial lameness, and in fact by all the signs of gene- 
ral tubercular disease. In another, which occurred in a boy eight years 
of age, it was preceded for several months by frequent complaints of 
intense headache, especially after taking active exercise, and by unusual 
languor, but no other symptoms. The boy was sent to boarding-school 
apparently well, and was suddenly attacked there. In two cases the 
meningeal symptoms were developed in the course of phthisis, whilst in 
a fifth they followed a state of general weak health, with dyspeptic symp- 
toms, which had lasted for several months. In the remaining twelve 
cases that I have seen, the invasion was sudden. 

First stage. — The headache, vomiting, and constipation persist and 
become more marked. Headache is a nearly invariable symptom in chil- 
dren old enough to describe their sensations, and is therefore very im- 
portant. In infants its presence is to be inferred when the child car- 
ries its hands frequently to various parts of the head, and presses strongly 
against it, and when the head is constantly rolled from side to side. It 
is generally frontal, and is usually referred to a point just over one or 
both brows. In other cases it extends over the whole head. It is com- 
monly severe, so that the child when old enough complains of it sponta- 
neously. In the case of a girl seven years old whom I saw, it was so 
severe that she cried frequently and bitterly, begged to have the doctor 
sent for, and submitted willingly to any remedy suggested with a view 
to its relief. It is thought that the acute, shrill cry of the disease, to 
which the term hydrencephalic has been applied, depends on the acuteness 
of this pain. It usually lasts throughout the first stage, and ceases only 
as the delirium and coma of the second stage come on. Vomiting is also 
a nearly constant symptom. Of 80 cases, collected from different sources 
by M. Barrier, it was absent only in 15, or less than a fifth. This symp- 
tom generally makes its appearance on the first day, rarely later than the 



SYMPTOMS. 379 

second or third, and lasts two or three days, and sometimes longer. In 
one case that I saw, it lasted eleven days, though it was but slight on the 
tenth and eleventh. The matters ejected from the stomach consist of the 
ingesta, and of mucus and bile in various proportions. It is commonly 
repeated two or three times a day. Constipation is even more important 
as a symptom than the one last named. Of 87 cases it was absent only 
in 7, according to Barrier. MM. Rilliet and Barthez state, however, 
that it exists at the beginning only in about three-fourths of the cases. 
Where there is diarrhoea, instead of constipation, at the invasion, as 
sometimes happens, the former symptom almost always depends on tuber- 
cular disease of the intestine. Even under these circumstances, however, 
the diarrhoea is sometimes arrested, and constipation substituted under 
the influence of the cerebral disease. The constipation generally persists 
obstinately for several days, and then gives way under the influence of 
purgative medication, or is replaced spontaneously by diarrhoea with in- 
voluntary stools towards the termination of the case. 

In connexion with the three important symptoms just described, there 
are others, which though less characteristic, are of much assistance in 
forming the diagnosis. The child is dull and sad, or excited and irritable 
by turns ; he shuns the light, or closes the eyelids and contracts the 
brows when it is thrown upon the face ; the sleep is restless and disturbed, 
and accompanied by grinding of the teeth • and he utters from time to 
time, both sleeping and waking, the peculiar, shrill, sharp, and sudden 
scream, which seems to depend upon internal pain, probably headache, 
and which has been called by Coindet the liydr encephalic cry. The intel- 
lectual faculties remain undisturbed in the majority of the cases during 
the first few days, and this fact, which is so contrary to what might be 
expected, is one of the utmost importance in the judgment of the case. 
I remember being asked by the little girl seven years old, to whom I 
have already referred, " why it was that she saw double, why she saw 
two mothers and two doctors V At the time when she first asked the 
question there was no perceptible strabismus,, but on the following day, I 
thought I could detect a deviation of one of the eyes from its proper 
axis, and on the third day, the deviation was very marked ; though the 
poor child still wondered why she saw two objects instead of one. In 
another case, in a boy five years old, there was no disorder of the intelli- 
gence until the eleventh day, when there was slight delirium alternating 
with somnolence ; yet it was clear from the first that the attack would 
prove one of tubercular meningitis, from the coexistence of violent frontal 
headache, obstinate vomiting, constipation, slow and irregular pulse, and 
the absence of other local or general symptoms. In only a fifth of the 



380 TUBERCULAR MENINGITIS. 

cases observed by MM. Rilliet and Barthez was there perversion of the 
intellectual faculties at the invasion. Let us observe, moreover, that even 
when children present some of these disorders early in the attack, they 
generally consist only of slight delirium, dulness of the intelligence, slow- 
ness and hesitation in answering questions, disposition to somnolence, 
excessive irritability and peevishness of temper, and what is more im- 
portant and characteristic than any of these, perhaps, of a certain expres- 
sion of the countenance, and particularly of the look, which is expressive 
of astonishment or of the utmost indifference. The look is in fact fixed 
or staring, like that of one in a mild ecstacy. Even when these symp- 
toms, exist, however, at an early period, they not unfrequently alternate 
with the most perfect clearness of the faculties, so that the physician in 
private practice, who sees his patient only at long intervals, and for a few 
moments at a time, should never venture to disbelieve without due con- 
sideration, the account of the mother or nurse as to their occasional pre- 
sence during his absence, even though never observable during his visit. 
I knew this to happen in regard to a boy eight years old, whose mother 
constantly insisted to the physician in attendance, that during his absence 
the child occasionally presented slight delirium, and a wild uncertain 
expression of the countenance, which made her fear that his brain might 
be affected. As the child's intelligence was perfect, however, whenever 
the doctor saw him, he determined that the mother was fanciful through 
over-anxiety, and ascribed the sickness to a bilious disorder of the stomach. 
After a few days the case developed itself, and the boy died with every 
symptom of tubercular disease of the brain. 

When disorders of intelligence do not occur in the early days of the 
attack, they usually make their appearance about or soon after the 
fifth day. 

During the first stage the coloration of the face ought to be noticed. 
It is generally paler than natural, though from time to time a sudden flush 
of redness may be seen to pass over it. The condition of the senses is 
natural, except that the acuteness of the eye, ear, and sometimes that of 
touch, are exalted, so that the child avoids the light, starts at sudden or 
loud sounds, and cries when it is touched or moved. The respiration be- 
comes unequal and irregular, and is interrupted by sighing or yawning. 

Convulsions rarely occur in the first stage. MM. Rilliet and Barthez 
conclude that meningitis without complication of tuberculous disease of 
the cerebral substance, never begins with convulsions, and that, on the 
other hand, whenever they appear at the invasion, or occur frequently and 
with violence, they almost always coincide with tubercles of the substance 
of the brain. 



SYMPTOMS. 381 

The tongue remains moist ; the appetite is not entirely lost ; thirst is 
moderate ; the constipation continues, unless removed by treatment ; the 
abdomen becomes retracted, so that its walls approach very closely to the 
spinal column, and allow us to feel the pulsations of the aorta without 
using more than very slight pressure. The latter symptom comes on 
gradually and is generally well marked by the sixth day or a little later. 
MM. Rilliet and Barthez regard it as a very important sign, and state 
that they have observed it almost exclusively in cerebral affections. They 
think it depends not upon contraction of the abdominal muscles, but upon 
retraction of the intestines. I can add my feeble support to the evidence 
of the above authorities as to the value of this symptom. It has been 
very marked in the cases that I have seen. 

The state of the circulation is of the utmost importance in forming the 
diagnosis. So true indeed is this, that Dr. Whytt of Edinburgh, whose 
description of acute hydrocephalus, published in 1768, has been most 
highly commended by all recent writers as a singular instance of accu- 
rate observation, makes three stages of the disease, each of which is cha- 
racterized by the state of the pulse. In the early part of the attack the 
pulse is accelerated, rising to 110, 120, or, according to Whytt, in a few 
cases to 130 or even 140. At the same time it is neither full nor tense 
as a general rule, but rather soft and compressible. This condition of the 
pulse changes, as we shall find, in the middle period of the disease, 
and again shortly before the fatal termination. The heat of skin is 
usually moderate at this time, as might be supposed from the state of the 
circulation. 

Second stage. — This stage begins about the time that the more marked 
nervous symptoms show themselves. The headache generally subsides or 
ceases at the beginning of this period and gives place to delirium. This 
occurs usually somewhere between the sixth and twelfth days. The deli- 
rium which occurs has been generally supposed to be always mild and calm. 
MM. Rilliet and Barthez state, however, that in one-third of their cases 
it was intense, and accompanied with cries, agitation, and frequent changes 
of position. In most of the cases it is mild, and is manifested in older 
children by their muttering unintelligible words, by inattention to what is 
going on around them, by an expression of wildness and astonishment, 
and by hesitating answers to questions. In children under two years of 
age there is no proper delirium. There is, however, an analogous condi- 
tion which is characterized by disorder of the two faculties of attention 
and perception. This symptom seldom lasts more than two or three days, 
and generally alternates with somnolence, so that the child is either dozing 
and sleeping, talking in its sleep, or frequently waking with loud cries 
and restlessness. It has often been asserted that general and special sen- 



382 TUBERCULAR MENINGITIS. 

sibility were very much exaggerated at some period of the disease. MM. 
Killiet and Barthez state, however, that in only four of their patients was 
the general sensibility exalted. Much more generally it is diminished in 
the early part of the second stage, or about the seventh day, and completely 
abolished towards the end. The face in the second stage is almost always 
pale, or pale and flushed alternately. During this stage, and especially dur- 
ing the latter part of it, it is very common to see sudden alterations in the 
color of the face. Sometimes without any apparent cause, but more fre- 
quently from disturbances of any kind, as from pain or from external in- 
fluences acting upon the child, such as moving it, or the administration 
of food or medicine, the face becomes suffused of a more or less deep 
pinkish or scarlet tint, the color beginning faintly at first and gradually 
deepening and expanding until it covers the whole face and forehead, and 
then as gradually fading away. It is during this stage also that another 
symptom, which I have often noticed, and to which M. Trousseau has 
called attention, may usually be observed. M. Trousseau refers to it as a 
red line remaining upon the skin of the forehead or abdomen when the 
finger has been drawn across it. I had often remarked, before knowing 
that M. Trousseau had drawn attention to this phenomena, that the 
slightest pressure with the finger on any part of the face or forehead, 
caused the appearance at the point of pressure, of a spot of a peculiar 
pink or rose color, which, like the flush above referred to, began faintly, 
became more or less deep in tint, remained a few moments, and then as 
gradually faded away. This is no doubt one of the diagnostic symptoms 
of the disease. I do not recollect to have seen it in any other disease, 
and in this I believe it may always or nearly always be detected. 
Occasionally contractions pass over the features, giving rise to grimaces, 
after which the countenance resumes its expression of indifference and 
stupor. The eyelids are generally only partially closed, and between 
them the globes of the eyes can be seen to oscillate and move in various 
directions, as though by some automatic force. 

As the case progresses the nervous symptoms become more and more 
marked : somnolence gradually deepens into coma ; the delirium becomes 
less and less frequent ; and the child no longer observes what is going 
on, nor answers questions. As the somnolence and coma increase, various 
lesions of motility make their appearance, consisting, in order of frequency, 
of paralysis which is generally partial, contraction with rigidity of the 
limbs, stiffness of the trunk, spasmodic closure of the jaws, carphologia, 
subsultus tendiiium, and convulsions. The paralysis is almost always 
partial and of very limited extent, affecting, for instance, the jaw, the 
orbicularis muscles of the eyelids, the levator of the upper eyelid, the 
tongue, or one side of the face. It is very rare to see one of the limbs 



SYMPTOMS. 383 

paralysed. Contraction with rigidity of the muscles is an important 
symptom, hut is not always present. When it exists it generally appears 
at an advanced period of the attack, commonly between the seventh and 
thirteenth days, and is usually partial. It may affect either the extremi- 
ties, trunk, or inferior maxilla. It is seldom permanent, but after lasting 
one or two days, disappears, to reappear at a later period. The carpho- 
logia, subsultus, and chewing motion of the under jaw generally occur 
only a few days before death, and last but one or two days. MM. Rilliet 
and Barthez state that convulsions never occur at the commencement of 
meningitis, unless there be a complication of tubercular affection of the 
cerebral substance, and that they are rarely frequent or violent during 
the course of the case, except under the same circumstances. In one of 
the cases that came under my charge, a severe and prolonged convulsive 
seizure did occur, however, on the very first day of the attack of the 
disease. The subject of the case was a boy between four and five years 
old. The death took place on the eighteenth day, and the autopsy showed 
no tubercular disease of the cerebral substance. It is proper to state, 
however, that the child had eaten on the morning of the day that he was 
attacked, a most unwholesome meal, and it is very possible, as I in fact 
supposed at the time, that the convulsions were caused by the presence 
in the stomach of a quantity of undigested food. When they do occur 
in tubercular meningitis, they may be limited to the extremities, upper 
lip, eyeballs, or they may be general. Sometimes the child dies in a 
convulsion. They are generally much less important as a symptom, 
according to M. Valleix, than in simple acute meningitis. 

The decubitus in the early part of the second stage is generally lateral, 
with the thighs flexed upon the pelvis, the legs upon the thighs, the 
arms applied against the thorax, the elbows bent, and the hands placed 
in front. At this time the child will still occasionally move its position 
with facility, showing that strength is not by any means entirely lost. 
At a still later period the decubitus is dorsal. In the latter part of the 
first and early part of the second stage, the pulse, which we have ascer- 
tained to be accelerated at the invasion, falls to the natural standard, or 
becomes slow, and at the same time irregular. From 110 or 120, as it 
was, it now sinks to 90, 80, 60, or, as happened in one instance to M. 
Guersant, to 48 in the minute. Coincidently with this change it almost 
always becomes irregular. The irregularity affects both its force and 
quickness, so that a strong pulsation may be followed by a feeble one, or 
the rhythm may be regularly or irregularly intermittent. The irregu- 
larity varies greatly at different periods of the day, or within short spaces 
of time, so that the pulse is found to be very slow at one moment and 
much more frequent the next. On this account it is necessary to examine 



384 TUBERCULAR MENINGITIS. 

it on different occasions. Slowness and irregularity of the circulation 
are important as a means of diagnosis, since it has very rarely been met 
with as a permanent condition, except in the tuberculo-inflammatory affec- 
tions of the brain and its dependencies. Towards the termination of the 
disease, generally speaking two or three days before death, the pulse rises 
again in frequency, so that it counts at first 112 or 120, and gradually 
increases to 140, 160, or even 200, the day before, or that on which death 
takes place. Simultaneously with this change it also becomes extremely 
feeble and small, and often ceases to be perceptible at the wrist on the 
last day. The heat of skin increases with the acceleration of the pulse. 
During the last few days the surface is often covered with an abundant 
perspiration ; the tongue becomes dry ; the teeth and gums are fuligi- 
nous ; the exhaustion increases ; the respiration becomes stertorous, un- 
equal, difficult, and anxious, and at the very last attended with great 
dyspnoea ; and the urine and stools are discharged involuntarily. Death 
finally occurs in this condition, or is hastened by an attack of convulsions. 
In some cases it is most lingering. In one instance I expected the death 
of a young child in this disease every day for eight in succession. 

The duration of tubercular meningitis is exceedingly variable in dif- 
ferent cases. As a general rule it lasts between eleven and twenty days, 
though it may continue a considerably longer time. Rilliet and Barthez 
have never known death to occur before the seventh day. 

Diagnosis. — The diseases with which tuberculosis of the meninges is 
most likely to be confounded, are simple meningitis, and typhoid fever. 
It might also be confounded, though this is much less probable, with the 
cerebral symptoms which complicate the exanthemata and some local 
diseases, and to which as a group, M. Barrier has applied the term pseudo- 
meningitis. 

The diagnosis between tubercular and simple meningitis will be best 
understood from the following synoptical table extracted from the work of 
M. Valleix, and from a paper by M. Rilliet (Arch. Gen. de Med. t. xii., 
1846). 

SIMPLE ACUTE MENINGITIS. TUBERCULOSIS OF THE MENINGES. 

No antecedent symptoms. Antecedent symptoms of tubercles. 

Symptoms of the invasion more vio- Symptoms of invasion ordinarily less 

lqfit, more distinct, more characteristic, violent, occurring slowly, often insi- 

especially in idiopathic cases. diously. 

Violent delirium, very suddenly esta- Delirium less violent, often tranquil, 

blished; (phrenitic form of M. Rilliet.) appearing later, and arriving less ra- 
pidly at its highest intensity. 

In a certain proportion of cases, No convulsions at the commence- 

frightful convulsions at the commence- ment. 
ment; (convulsive form of M. Rilliet.) 






DIAGNOSIS — PROGNOSIS. 385 

SIMPLE ACUTE MENINGITIS. TUBERCULOSIS OF THE MENINGES. 

Very severe headache; suffusion of These symptoms sometimes absent, 

the face, photophobia, etc. ; these symp- especially at the commencement ; they 

toms strongly marked. are almost always less strongly marked. 

Vomiting more frequent, and more Vomiting less frequent, and less 

abundant. Constipation moderate. Pulse abundant. Constipation very obstinate, 

often slower than natural at the com- Pulse more frequent, stronger, less ir- 

mencement ; more irregular. regular. 

Progress continuous, without percep- Progress continuous, but ordinarily 

tible remissions. with very perceptible remissions. 

Duration shorter; from one to six Duration much longer, 
days, rarely longer. 

Before quitting the subject of the diagnosis of these two affections, it is 
desirable to state for the information of the reader, that some of the 
highest authorities acknowledge it to be sometimes nearly or quite impos- 
sible to distinguish between them. This is the expressed opinion of MM. 
G-uersant, Rufz, Barrier, and Valleix. 

From typhoid fever tubercular meningitis is to be distinguished by the 
antecedent history of the patient, which often reveals the existence of a 
tubercular diathesis in the latter affection ; by the symptoms of the inva- 
sion, which in meningitis consist of severe and persistent headache, fre- 
quent vomiting, and constipation, whilst in typhoid fever the headache is 
less severe and less persistent, the vomiting much less frequent, and the 
constipation replaced by diarrhoea; by the different characters of the 
febrile movement, which, in typhoid fever, is more marked, and attended 
with a frequent, full, and regular pulse, while in meningitis it is less 
marked and is accompanied after a few days by slowness and irregularity 
of the pulse; lastly, in meningitis, the constipation is obstinate, the abdo- 
men retracted, and there are various important and characteristic lesions 
of motility, sensibility, and the senses; in typhoid fever, there is diarrhoea, 
the abdomen is distended and meteoric, there are characteristic rose- 
colored spots, whilst there are no considerable lesions either of motility, 
sensibility, or of the senses. 

It is unnecessary to do more than allude to the possibility of confound- 
ing the disease with the exanthemata, or with local diseases accompanied 
by cerebral symptoms, and particularly with pneumonia in very young 
children. The diagnosis must be made by careful consideration of the 
symptoms peculiar to each, and in the case of a local disease, by accurate 
physical examination of all the important organs of the body. 

Prognosis. — M. Barrier, in speaking of the prognosis of this affection 
says : " The gravity of tubercular meningitis is not surpassed by that of 
any other disease. Thoracic and abdominal phthisis, though almost con- 
stantly fatal, pursue a slower course, and last a longer time. We may 

25 



386 TUBERCULAR MENINGITIS. 

even allow as proved, that in a small number of cases, they are susceptible 
of cure, or may remain stationary for months or years. Unfortunately it 
is not so in regard to tubercular meningitis." Rilliet and Barthez re- 
mark : " For our part we have not seen a single case of tubercular menin- 
gitis terminate in recovery, and our experience confirms that of MM. 
llufz, Piet, Gerhard, Green, etc." They add that they have not been 
able to find any authentic cases of cure in the French journals. M. Val- 
leix is of opinion that after having acquired the conviction that a case is 
really one of tuberculosis of the meninges, we should regard the patient 
as lost; " for the exception that I have mentioned (a case belonging to 
M. Rilliet, then unpublished), even did no doubt as to the exactness of 
the diagnosis remain, ought not, standing by itself, to impart to us any 
real security." M. Guersant (Diet, de Med. t. xix. p. 403), seems to 
think it possible that the disease may sometimes terminate favorably in 
the very early stage, but adds that " such cases are always more or less 
doubtful, and seem to us to belong rather, for the most part, to simple 
meningitis." During the second period (that of slowness and irregularity 
of the pulse), he has scarcely seen one child in a hundred survive, and even 
then they perished at a later period of the disease, or of phthisis pulmonalis. 
Of those arrived at the third stage (marked by renewed frequency of the 
pulse, coma, and lesions of motility and sensibility), he has never seen 
any recover, even momentarily. Dr. George B. Wood (Pract. of Med. 
vol. ii. p. 365), states that he has "never seen a well-marked case of 
tuberculous meningitis end favorably." 

I shall quote but one more authority as to the prognosis of the disease. 
Dr. Robert Whytt (Works of Robert Why tt, published by his son, quarto, 
Edinburgh, 1768, p. 745), says : " I freely own, that I have never been 
so lucky as to cure one patient who had those symptoms which with cer- 
tainty denote this disease ; and I suspect that those who imagine they 
have been more successful have mistaken another distemper for this." 
My own experience coincides with the mass of evidence given above as to 
the hopeless fatality of the disease. The seventeen cases that 1 have seen 
all proved fatal. A case, however, came under my observation in 1850 which 
might, perhaps, be classed as a recovery from tuberculosis of the meninges, 
though not from tubercular meningitis, since there were no well-marked 
signs of inflammation of the membranes of the brain, though there was 
every reason to suppose that the symptoms depended on the deposit of 
tubercles in those membranes. The case was as follows : A girl between 
four and five years old, whose mother was then laboring under tubercular 
disease of the summit of one lung (which has since proved fatal), and who 
had lost several brothers and sisters with consumption, had had nearly 
constant cough during the winter of 1849-50. During the months of 



PROGNOSIS. 387 

April, May, and June of 1850, she had exhibited all the signs of indura- 
tion over the upper two or three inches of the right lung, before and be- 
hind, — marked dulness on percussion and bronchial respiration, but no rale. 
For these symptoms she had been treated with cod-liver oil, iodide of 
iron, opium for the cough, and good diet. From the middle of June she 
complained frequently of headache, had occasional vomiting without 
any gastric derangement, and was much disposed to be constipated. She 
had no appetite, grew thin, and was very languid, listless, and weak. On 
the 27th of June the mother thought she observed some squinting. On 
the 29th I found that the child had lost all power over the right muscles of 
the right eye, so that when she looked towards the right hand, she 
squinted dreadfully. She was dull and heavy, and vomited two or three 
times a day. The pulse was 62 to 75 or 80 ; there was a slight hitch in 
its beat, but no decided intermittence. The child said that she some- 
times saw two things instead of one. From this time until July 7th, she 
continued in much the same state. On the 1st July, finding that the 
eyes were quite yellow, and that the child was constipated, I ordered half 
a grain of calomel morning and evening. After three doses she was 
purged. This relieved her a good deal, there being less headache, more 
appetite, and an improvement in the color afterwards. But still there was 
ever}- day some vomiting, complaints of headache, and more or less list- 
lessness and heaviness in the morning, while in the afternoon she would 
brighten up and seem better. The intelligence continued perfect; the 
temper was rather irritable, but not very much so. 

The treatment after the 29th of June was calomel, given as above 
stated, from time to time, to keep the bowels soluble; cod-liver oil, a 
teaspoonful twice or three times a day, as the child would take it ; mus- 
tard foot-baths every day or two ; and meat, bread, and ice cream for diet. 
On the 5th July I ordered half a grain of iodide of potassium, three times 
a day, in addition to the oil. 

On the 11th July, she was taken, by my direction, to the sea-side, where 
the use of the oil and of the iodide of potassium was to be continued. 

On the 7th of August she was brought back from the sea-side, and I 
saw her on the 8th. I was astonished to see how well she looked. The 
strabismus had entirely disappeared. I was told that it had begun to 
diminish two weeks after the arrival at the sea, and had then gradually 
disappeared. She had grown somewhat, though not very much, fatter. 
Her whole appearance was very much improved. The coloration of the 
body, the expression of the face, were both much better; she was much 
stronger, running about, in fact, all day; she ate well, and with the 
exception of a little cough, and a rather delicate frame, looked very well. 



388 TUBERCULAR MENINGITIS. 

Except one day, she was well all the time at the sea-shore. On that day- 
she was feverish, had much headache and vomiting, and laid abed. The 
cod-liver oil and iodide of potassium to be continued. 

This child remained pretty well throughout the winter of 1850-51. 
There was no return of either the strabismus or the vomiting. She was 
thin, pale, and delicate-looking, coughed occasionally, and the solidification 
of the summit of the lung continued, but she was not confined to the house. 
Late in the winter she went south with her mother, and there, after having 
become quite stout and healthy during their travels, died of dysentery in 
April or May. The mother died in 1852 of phthisis, with large cavities in 
both lungs. 

I have seen but one other case which gave me the least reason for hope, 
after I had once supposed the child attacked with the disease. This occurred 
in a boy eight years old, who had been suffering for two weeks before I saw 
him with violent frontal headache, frequent vomiting, constipation, slight 
fever, and somnolence. I fully expected that this would prove to be an 
attack of tubercular meningitis. A large dose of calomel followed by 
castor oil, and free leeching to the temples, relieved him in two days per- 
fectly, and he has remained well ever since, though this was nearly eight 
years ago. 

Are we then to abandon all hope of deriving any good from medical means 
in the disease under consideration ? To this momentous question we ought, 
it seems to me, to respond in the negative. What then are the grounds for 
entertaining hope where, from the quotations given above, all that has as 
yet been done seems to have failed so completely ? They are first, the 
evidence of M. Guersant that he has seen cases which appeared to be tuber- 
cular meningitis recover in the first stage. Granted that they were cases 
of simple inflammation. But they were undistinguishable from the tuber- 
cular disease by one of the most celebrated of modern physicians. Surely, 
therefore, it may happen to men of inferior skill to meet with the same 
difficulty, or if I may so speak, to make the same mistake. It is said by 
M. Valleix, that M. Rufz, after determining at the autopsy, that a case 
which he had witnessed was one of simple meningitis, asserted that it 
would have been impossible to distinguish it from the tubercular disease 
during life. Again, M. Killiet has, according to M. Valleix, seen one 
case of recovery from what he believed to be the tubercular affection. I 
know of the occurrence of a case in this city, under the charge of one of 
my friends, than whom I believe no one can be more competent to make a 
correct diagnosis, in which, after the child had presented in regular order 
all the early symptoms of the disease, and had arrived at the last and most 
hopeless stage, perfect recovery, to his utter amazement, gradually took 
place. This child, when my friend last heard of it, three months after- 



TREATMENT. 389 

wards, was in all respects strong and hearty. No doubt the probabilities 
are that the case was one of simple meningitis, but who could have known 
this at the time ; and should it not deter us from abandoning all hope, 
and, as a consequence, all active treatment, when we seem to have under 
our hands a case of this dreadful malady. 

It is important, in tubercular meningitis, to avoid making a positive 
prognosis as to the period at which death will occur, notwithstanding that 
the patient may present every mark of an immediately fatal termination. I 
have already adverted slightly to this subject. On one occasion I expected 
the death of a patient with this malady for three days in succession, and 
on another, I visited a child for a week, during every day of which it 
seemed as though existence could not endure until the next. It had du- 
ring this time profound coma, subsultus tendinum, and enlarged pupils ; 
the eyelids were half open, the eyes constantly oscillating, or else rigidly 
distorted, and both corneas dimmed and slightly eroded, from constant ex- 
posure to air and light. Convulsions occurred from time to time, the 
pulse was variable and at times exceedingly frequent, and indeed every- 
thing threatened a speedy termination. MM. Rilliet and Barthez say 
" often have we inscribed upon our notes death imminent, and been asto- 
nished the next day to find still alive, children to whom we had allowed 
scarcely two hours of life." 

The symptoms which most positively indicate the near approach of 
death are : livid color of the face, sweats occurring about the face, glassy 
expression of the eye, dry and incrusted nostrils, very rapid pulse, and 
still more strongly, the various nervous symptoms mentioned, as carpho- 
logia, subsultus tendinum, and particularly general convulsions. 

Treatment. — The methods of treatment which have* been proposed at 
different times having all failed, it becomes very difficult and embarrassing 
to determine what ought to be recommended. As, however, there can be 
no doubt that simple meningitis has sometimes been mistaken for this 
affection, and as the state of the diseased organ after death proves the exis- 
tence of an inflammatory element in the disease, it would seem most rea- 
sonable to employ the antiphlogistic plan, until more extended observation 
and greater experience shall either discover another and better method, or 
show the entire futility of this. By this method we at the same time do 
what is most proper should the attack chance to prove one of simple in- 
flammation, and employ the means most likely to remove the inflamma- 
tion of the meninges which accompanies and is the consequence of the 
tubercular deposit. Moreover, from all that I have read and seen, it seems 
to me that whenever cases have been reported as cured or even only ame- 
liorated, it has been under the influence of antiphlogistic remedies, includ- 
ing calomel, and more or less powerful counter-irritants. 



390 TUBERCULAR MENINGITIS. 

In the first stage, the treatment ought to begin with bloodletting. It 
is preferable always to employ venesection, unless there be some positive 
contra-indicating circumstance. This is the expressed opinion of most 
writers. Some recommend opening the jugular vein as the most direct 
means of acting upon the cerebral circulation, while others propose that 
the operation be performed in some of the veins of the inferior extremi- 
ties, as effecting a useful derivation at the same time that it yields the 
requisite amount of blood. For my own part I have been satisfied to 
bleed at the usual place, unless there was some difficulty in finding a vein, 
in which event I have had recourse to the vessel running over the inner 
malleolus. The quantity of blood to be taken must depend on the age, 
constitution, and previous health of the patient. When the child is over 
two or three years old, with the appearances of good health, the quantity 
may vary between four and eight ounces ; in younger children it should 
rarely exceed four. The bleeding may be repeated if the pulse continues 
tense and the flushing of the face fails to subside after the first operation, 
or we may resort to leeehes or cups. MM. Rilliet and Barthez prefer 
local to general bleeding, and recommend that the leeches be applied to 
the anus or inferior extremities, in order to obtain a derivative as well as 
depletory effect. Where all remedies are of so little avail as they seem 
to be in the disease under consideration, it is difficult to decide on the most 
proper course, not only as to the selection of means, but as to the extent 
to which they are to be employed. It seems to me, however, that the 
advice given by the authors just quoted, to employ bloodletting only at 
the invasion of the disease, is the most prudent. They state that " em- 
ployed in the second and particularly in the third stages, their inevitable 
effect is to increase the nervous symptoms ; the delirium becomes more 
violent, and the coma, if it existed, augments ; we have several times ob- 
served this." Dr. G-erhard, whose opinions on this subject are deserving 
of great weight, advises that local bleeding be directed " so long as the 
patient can bear it, that is to say, until he becomes pale, and the flush is 
gone, whether the other symptoms abate or not." (Clinical Lect. by 
Graves and Gerhard, Phil. 1842, p. 473.) 

After bleeding it is proper to employ some kind of counter-irritation, 
which may consist of blisters applied to the nape of the neck, or behind 
the ears, to be kept discharging for several days, of sinapisms to the 
extremities, and of mustard pediluvia. To be of any probable service 
these remedies ought to be perseveringly and patiently employed for 
several days, or during the whole of the second stage. 

The head ought to be kept cool by means of cold applications, consist- 
ing of cloths wet with cold water, of affusions with cold water, or, as has 
been proposed by M. Guersant, by the use of irrigation as employed in 



TREATMENT. 391 

surgery. M. G-uersant prefers this mode of applying cold to any other, 
believing it to be the most convenient and comfortable to the child, and 
from its continuous action, the most efficacious. To make use of it the 
hair ought to be shaved or closely cut, and the child is to be placed upon a 
mattrass without a pillow, and with its head near the edge of the bed. 
The head is then covered with compresses of soft rag, or better still, of 
patent lint, while under it is placed a piece of oiled silk, or india-rubber 
cloth, so arranged as to keep the thorax from being wet, and doubled 
into a gutter above to convey the water off into a vessel placed on the 
floor. A bucket or basin filled with fresh, cool water, is placed near the 
head of the bed, and from this a syphon made of lint or lamp-wick is so 
arranged as to convey a stream of water upon the compresses covering 
the head. If the heat of the whole body falls so much as to threaten 
collapse after the irrigation has been continued for some time, the stream 
of water should be stopped, and compresses merely, wet with water not 
quite so cool, kept on the head. The latter precaution is necessary in 
order to prevent injurious reaction from the sudden and total removal of 
so powerful a sedative as irrigation proves to be. 

Some practitioners prefer the use of ice in a bladder. This seems to 
me, however, too severe a remedy to be long continued, and I would 
therefore rather use only cloths wet with iced water, or irrigation. Dr. 
Abercrombie is of opinion that the application of cold is by far the most 
powerful local remedy that we have. M. Gendrin recommends cool or 
cold affusions over the whole surface, the temperature to be proportioned 
to the heat of the skin. When there is but little heat of head, only a 
slight febrile movement, and the headache is not relieved by cold appli- 
cations, Guersant recommends the substitution of warm poultices to the 
scalp, in the place of irrigation or cold applications. 

Purgatives ought to be employed so as to secure a moderately free 
state of the bowels. To use them to such an extent as to procure very 
frequent and watery stools, with the view of obtaining a strong derivative 
action upon the intestinal mucous membrane, can only, it seems to me, 
be injurious, by increasing the febrile reaction and nervous disorder 
already existing. Dr. Abercrombie, it should be stated, however, regards 
purging as the most efficient treatment that can be employed. He says, 
" In all forms of the disease, active purging appears to be the remedy 
from which we find the most satisfactory results." He recommends the 
use of croton oil. Calomel, on account of its powerful antiphlogistic and 
sedative action, is the best purgative to be given at an early period of the 
disease. From two to eight grains, according to the age of the child, 
may be exhibited in a single dose, to be followed in several hours by 
some other purgative. This may be castor oil, jalap, magnesia, rhubarb, 



392 TUBERCULAR MENINGITIS. 

extract of senna, or salts. Remedies of this class should be repeated 
from time to time throughout the case, according to the condition of the 
bowels. 

Besides antiphlogistics, counter-irritants, and evacuants, which have 
just been considered, there are two other remedies which have obtained 
some reputation in the treatment of the disease. These are calomel, given 
as an alterative, and iodine. Calomel is highly recommended by most of 
the English writers on acute hydrocephalus, and is asserted to have effected 
cures when it has been pushed to such an extent as to produce salivation. 
But little dependence, however, can be placed on these assertions, as in 
all probability, the reported recoveries occurred in cases of simple menin- 
gitis. The French writers, whose correctness of diagnosis is probably 
more to be depended upon, speak of having used it in very large quan- 
tities without any success. It was given to many of the patients of MM. 
Billiet and Barthez, in the quantity of from six to ten, increased to 
twenty grains, in twenty-four hours, in connexion with frictions with 
mercurial ointment, of which two drachms and a half were used at first, 
and the quantity afterwards doubled and trebled. They state that sali- 
vation did not occur in any of the cases, though fetor of the breath and 
inflammation of the gums were of frequent occurrence. It has already 
been stated that all the cases of these gentlemen proved fatal. Calomel 
may be given, as has been remarked, in purgative doses, at the beginning, 
and for the purpose of procuring its specific effects, With the latter view 
the dose may be from a quarter of a grain to a grain, every hour or two 
hours. Mercurial inunction in conjunction with the internal administra- , 
tion of the remedy, has been highly recommended by several writers as an 
efficient means of procuring the full effect of the drug upon the constitu- 
tion. About a drachm of the ointment is to be rubbed into the insides of 
the arms and thighs morning and evening, and the quantity gradually 
increased if no effect is produced. For my own part, I will merely state 
that I have never known calomel given in large quantities, in order to 
procure salivation, of the least benefit in the disease. On the contrary, I 
cannot but think that the violent irritation of the digestive mucous mem- 
brane which it has determined, whenever I have used it largely, and the 
inflamed, irritated condition of the mouth which it caused in one case, 
must have been a serious aggravation of the state of disease under "which, 
the constitution was laboring. Mercury is well known to be an injurious 
and dangerous remedy in the tubercular diseases of adults, having for its 
effect to increase the dyscrasia of the constitution, which always exists, 
and thereby to hasten the progress of the malady. Why it should have a 
different effect in children is difficult to understand. It may be said, to 
be sure, that in the disease we are considering, it is given to overcome the 



TREATMENT. 393 

inflammatory element of the malady, which, for the time, constitutes the 
danger of the case, and also to allow the patient the chance of its benefi- 
cial operation should the disease happen to be one of simple meningitis. 
But we are of those who deem it against morals to risk a wrong that good 
may perchance arise. I would, therefore, in a case which I believed, after 
mature and careful consideration, to be one of tuberculous meningitis, use 
mercury merely for its temporary sedative action, and not in the large 
quantities recommended with a view of obtaining its peculiar action, at 
least not until further evidence of its utility is brought forward. In sup- 
port of the view just expressed, I will quote the opinion of Dr. John 
Abercrombie (Diseases of the Brain and Spinal Cord, Philad. ed., 1831, 
p. 173-6): " Mercury has been strongly recommended in that class of 
cases which terminates by hydrocephalus, but its reputation seems to stand 
upon very doubtful grounds. In many cases, especially during the first 
or more active stage, the indiscriminate employment of mercury must be 

injurious In the preceding observations, I shall perhaps be 

considered as having attached too little importance to mercury in the 
treatment of this class of diseases, particularly in the treatment of hydro- 
cephalus ; but in doing so, I have stated simply what is the result of an 
extensive observation, .... and I confess, the result of my own 
observations is, that when mercury is useful in affections of the brain, it 
is chiefly as a purgative." 

It has been recommended within a few years, by Sir B. Brodie, to 
employ mercurial inunction as especially applicable in using mercury for 
children. He advises that a drachm or more of the ointment be spread 
upon one end of a flannel roller, which is to be applied, not very tight, 
around the knee ; repeating the application daily. " The motions of the 
child produce the necessary friction; and the cuticle being thin, the 
mercury easily enters the system." The editors of the journal in which 
this communication is made (Braith. Retrosp. of Med., vol. iv. 1846, p. 
147, from Quart. Med. Rev., July, 1846, p. 169), state that they tried 
this plan in a case of acute hydrocephalus, in which some of the most 
urgent and fatal symptoms were present, " such as very dilated pupils, 
constant convulsions, hemiplegia, and more or less stertorous breathing ; 
in short, so violent were the symptoms, that we considered the case per- 
fectly hopeless; but on reflecting on Sir Benjamin's method, we ordered 
strong mercurial ointment to be smeared on each leg, every twelve hours, 
and covered with a stocking made to tie tightly above the knees. The 
symptoms soon began to abate, and by following this up with small doses 
of iodide of potass, frequently repeated (gr. i. every three or four hours), 
the head symptoms vanished. 



394 TUBERCULAR MENINGITIS. 

In a second case, the same set of symptoms were approaching, but 
were stopped by the same mode of treatment." 

It has been proposed to employ iodine because of its good effects in 
different scrofulous and tuberculous diseases. I am not aware of its 
having been tried in any considerable number of cases. M. Rilliet, how- 
ever (Loc. cit., t. iii. 1847, p. 308), states that it has entirely failed in 
his hands in the tubercular form of the disease ; the only influence which 
it seemed to exert was to cause the immediate suspension of the coma. 
This was its effect also in a case in which I employed it, that of a girl 
seven years old, to whom I gave two drops of Lugol's solution three times 
a day, from the thirteenth to the twentieth day, when she died. The 
day before her death she seemed to improve somewhat, and I was in 
hopes that it had been of some service. The amelioration did not con- 
tinue, however, and I am now disposed to believe that the change was 
one of those which often take place naturally in the disease. In another 
case of a boy five years old, I gave it in the form of the iodide of potas- 
sium, a grain four times a day, from the tenth to the eighteenth day, 
when he died. I could not perceive that it exerted the least influence on 
the progress of the disease. It is, nevertheless, a remedy which ought 
to be tried. I would recommend the use of iodide of potassium in doses 
of a grain every three or four hours for children two years of age. It 
ought to be begun with as soon as the acute symptoms have been suffi- 
ciently reduced by bloodletting and purging, and continued in connexion 
with counter-irritants and cold to the head. 

When the convulsive symptoms are violent and distressing, they may 
often be moderated by the use of a warm bath, which must be carefully 
given, and by the administration of some of the antispasmodics. I 
prefer for this purpose the fluid extract of valerian, of which from three 
to five drops may be exhibited every two or three hours to young chil- 
dren, and a larger dose to those who are older. 

As a general rule, narcotics of all kinds are to be avoided, from their 
effect of increasing the constipation, and exciting more or less the cere- 
bral circulation. When, however, neither antiphlogistics, evacuants, nor 
cold or warm applications relieve the sufferings of the child, it would be 
proper to employ small laudanum poultices or opium plasters upon the 
forehead or temples, or we may use morphia by the endermic method. 

The treatment described in the preceding pages, is that which is proper 
for cases of the disease occurring in subjects previously in good health, 
or evincing but few signs of the tubercular cachexia. When, on the 
contrary, it occurs in children with extensive tubercular affections of 
other organs, by which they are already weakened and exhausted, the 
treatment must of course be modified to meet the circumstances of the 






PROPHYLACTIC TREATMENT. 395 

case. It ought to consist chiefly of local bleedings used with great mode- 
ration, of purging when constipation is present, of counter-irritants, of 
cold applications, and of an early use of iodine or of the iodide of iron. 
We should recollect that experience has long since shown the weakness 
of our art in such cases, and for that reason avoid such a degree of inter- 
ference as might possibly abridge the little span of life allowed the patient 
by this relentless malady. 

Prophylactic Treatment. — It must be evident that the prophylactic 
treatment is of especial importance in a disease so little amenable to 
curative means as the one under consideration. When therefore there is 
reason to suspect a tendency to tubercular meningitis in a child, either 
from the fact that other children in the family have perished with it, or 
from a bad state of the general health and frequent complaints of head- 
ache, it becomes proper and necessary to regulate both the moral and 
physical education with a view to its prevention. For this end the 
hygienic management of the child ought to be such as is best calculated 
to prevent the formation or development of tubercles in the constitution. 
During infancy, such a child should be nursed, if this be possible, by a 
strong, hearty woman, with an abundant flow of milk. If the mother is 
not possessed of these qualities, if there be, indeed, the least doubt upon 
the point, she ought without hesitation to give up the pleasure of nursing 
the child herself, and procure for it a wet-nurse of the kind described. 
This alone will, in all probability, often make the difference between a 
vigorous and fragile constitution. When the time for weaning arrives, 
that change ought to be made with the greatest care and circumspection. 
During and for some time after weaning, the diet must consist principally 
of milk preparations and bread, and of small quantities of light broths, 
or of meat very finely cut up. As the child grows older, the meals ought 
to be arranged at regular hours, and should consist of four in the day. 
The principal food must be bread and milk well chosen, well-cooked 
meats, and rice and potatoes as almost the only vegetables. After the 
first dentition is completed, a moderate use of ripe and wholesome fruits 
may be allowed, but always with care, in order to avoid injury to the 
digestive organs, and also so as not to mar the appetite for more whole- 
some and nutritious food. . Coffee and tea ought to be forbidden at all 
times. It is best that the child should not even taste them, so that it 
may not be tormented with the desire of having what is improper. 

After diet the most important points in the treatment are air and 
clothing. The child should inhabit, if possible, a large, dry, well-venti- 
lated room, which ought to be kept as cool as possible in summer, and 
moderately warm in winter. Not a day should be allowed to pass, unless 
the weather is totally unfit, without the child's being sent for several 



396 TUBERCULAR MENINGITIS. 

hours into the open air, and I believe that it is much better for it to 
walk than ride, unless the weather be very hot. The clothing ought to 
be suitable to the season, cool in summer, and warm in winter. In our 
country there is a great inclination to harden children by dressing them 
very slightly in cold weather ; so that they frequently suffer from catarrh, 
pneumonia, and spasmodic croup, brought on by improper exposure. 
This cannot but be wrong in a child who shows the least evidence of a 
tendency to tubercular affections. . 

For my own part I am fully convinced from what experience I have 
had of the diseases of children, that by far the most certain and effectual 
means of preventing the development of a tubercular, or indeed any other 
cachexia in a child, is to have it brought up in the open country, or in 
some healthy village, until the epoch of puberty has passed by safely. A 
very good plan for parents whose occupations compel them to live in cities 
or large towns, is to have their residence a few miles in the country and 
to come to town every day. Children brought up in this way have a far 
better chance of obtaining strong and vigorous constitutions, than those 
reared entirely in the close and confined dwellings and streets of crowded 
cities. 

When a child, who, from the health of its parents, or from its own ap- 
pearance, may be suspected of having any tubercular or scrofulous taint in 
its system, becomes subject to frequent attacks of apparently causeless 
headache, and especially when such headaches are associated with a con- 
stipated habit of body and with occasional vomiting, it ought to be looked 
upon as threatened with tubercular disease of the brain. Under these 
circumstances I would advise that, in addition to the measures just now 
recommended as to diet, dress, exercise in the open air, and a residence in 
the country, blisters be applied occasionally behind the ears, that it be put 
at once upon the use of cod-liver oil, iodide of potassium, or iodide of iron, 
and mild laxatives, and that these be persevered in for several weeks or 
months, until in fact the strength and general health are restored, and the 
headaches cease. If the child is of an age to be going on with its educa- 
tion, this should for the time cease, or be carried on in such a way as to 
avoid all excitement or fatigue. A case occurred to me in the course of 
the year 1852, which showed, I think, very clearly, the utility of these 
measures. 

A boy between seven and eight years old, whose mother had died of 
well-marked phthisis a few months before he was put under my charge, 
had been losing flesh and strength, and suffering from occasional headache, 
for some time before I was called to see him. I found him in bed com- 
plaining of severe frontal headache, — so severe at times, and usually in 
the after part of the day, as to cause great distress, with crying. The in- 



PROPHYLACTIC TREATMENT. 397 

telligence was perfectly natural. The child was rather dull and listless, 
from suffering and from weakness, but not from any want of a healthful 
state of the mental operations. There was no sign whatever of spasmodic 
or paralytic affection. In the morning the skin was cool and natural, but 
in the afternoon it became warm and dry, but not very hot. The pulse 
was 62 to 68, and though not actually irregular, it was halting or hesi- 
tating. There was occasional, but not frequent, unprovoked vomiting, 
and he complained often of sick stomach, even when he did not vomit. 
The bowels were very much constipated, and had been a good deal so for 
some weeks previous to his falling actually sick. There was no cough, no 
sore throat, and no soreness about the abdomen. The tongue was moist, 
soft, slightly furred, and not red nor gashed. The urinary secretion was 
healthy. Physical examination showed the lungs and heart to be without 
disease. 

The treatment during the first week was small doses of calomel and 
rhubarb, half a grain of the former to two of the latter, given for a day, 
and followed by syrup of rhubarb and fluid extract of senna, until the 
bowels were copiously evacuated. After this the bowels were kept soluble 
by the administration every day, or every other day, of doses of Selzer 
powder, sufficient to produce the effect. Blisters were applied behind the 
ears. In the after part of the day, when the head and body became 
heated, cooling applications were made to the head, and the feet were put 
into mustard water, once, twice, or three times. Two grains of iodide of 
potassium were ordered to be given three times a day. The diet was to 
be light, but nutritious. It was to consist of bread and milk and a soft 
boiled egg in the morning, oysters or light meats with rice for dinner, and 
milk with bread in the evening. Of these he was to have any reasonable 
quantity that he might desire. Under this treatment he improved slowly, 
with occasional drawbacks, for a week, when the iodide of iron was substi- 
tuted for the iodide of potassium. The bowels continued very costive, 
requiring daily doses of the Selzer powder ; the headaches diminished in 
frequency, duration, and severity ; the pulse went up to 72 and 78, and 
became more free and even ; the appetite had improved, but the child 
remained still very weak, pallid, and quite emaciated. After another 
week, as he continued to mend, and the stomach bad become stronger, 
cod-liver oil was ordered in addition to the iron ; a teaspoonful was to be 
taken three times a day, in a wineglassful of table beer. As he gained 
strength, the amount and kind of food was increased. He was, indeed, 
encouraged to eat heartily of plain and digestible substances. 

He now improved gradually in health. The headaches subsided, and 
finally ceased ; the bowels became soluble ', the appetite grew hearty and 
strong, and all feeling of nausea disappeared ; he regained his strength, 



398 SIMPLE MENINGITIS. 

flesh, and color, so that at the end of two months, I saw him looking quite 
fat and well. The iodide of iron and cod-liver oil were, however, to be 
continued for a month longer. 

As to the particular means likely to be of service in preventing a direc- 
tion of tubercular cachexia towards the brain, such as might produce tuber- 
culosis of that organ, we have only to propose the course recommended by 
different writers, viz., to keep the head cool, by not allowing it to be very 
warmly covered, and by keeping the hair short ; to keep the extremities 
warm ; to avoid stimulating the intellectual faculties to any considerable 
extent by education, until after eight or ten years of age ; and to use every 
means to preserve the general health in a sound and pure condition. Some 
recommend the long-continued employment of a powerful derivative from 
the brain, as a small blister on the arm, or a seton in the neck. It seems 
to me, however, that such remedies ought not to be used unless there are 
positive symptoms of a tendency to cerebral disorder. The caution not to 
interfere much with eruptions which nature may have thrown out upon 
the scalp is, I believe, wise and prudent. 



ARTICLE II. 

SIMTLE MENINGITIS. 

Definition ; Synonymes ; Frequency. — By this term is understood 
inflammation of the membranes of the brain, independent of tuberculosis 
of those tissues, or of other organs of the economy. 

The disease was for a long time confounded with tubercular meningitis 
under the titles of water on the brain, dropsy of the brain, and acute 
hydrocephalus. It has also been called arachnitis; and more rarely 
phrenitis. 

Its frequency is much less than that of tubercular meningitis. It 
appears that MM. RilHet and Barthez, during their researches, met with 
only five cases of this disease, while they report thirty-three of tubercular 
meningitis. Bouchut states that he has met with two cases of simple 
meningitis to six of tubercular disease, whilst Barrier reports only four of 
the former in nearly thirty autopsies of meningitis. He states, however, 
that he has met with three cases of recovery, all of which he believes to 
have been instances of the simple form. Fabre and Constant met with 
nine cases of simple to twenty-seven of tubercular meningitis in a period 
of two years, at the Children's Hospital of Paris. {Bibliothlque du Med. 
Prat. t. vi. p. 166.) 



CAUSES — LESIONS. 399 

Causes. — The causes of simple meningitis are not very clearly ascer- 
tained. It would appear, however, that the disease is more common in 
infants than older children. M. Rilliet, who has recently published a very 
valuable paper on this affection (Arch. Gen. de Med.) t. xii. 1846), 
divides it into two forms, the convulsive and phrenitic, the former of 
which he believes to be most common under two, and the latter between 
five and fifteen years of age. This author is disposed to think, from the 
fact that the disease is most frequent in the first and ninth years of life, 
that the process of dentition has something to do in its production. It 
appears also to be more frequent in boys than girls, and in robust than in 
weak constitutions. Guersant has known it to follow long-continued 
exposure to the sun in several instances, particularly in young infants • 
MM. Rilliet and Barthez report a case of the same kind, and Rilliet (Loc. 
cit.) another ; other causes cited by authors are injuries upon the head, 
such as blows, falls, and wounds. One other cause I will mention, which 
ought to be known to every practitioner. This is the attempt to cure 
chronic eruptions of the head, especially by too active a treatment. A 
case of this kind is given by MM. Rilliet and Barthez, another by Rilliet, 
and I am acquainted with one myself. 

The disease sometimes occurs in an epidemic form. 

Anatomical Lesions. — The dura mater is generally much injected, and 
its sinuses, together with the large cerebral veins, contain coagulated or 
semi-coagulated blood, sometimes in large quantities. On opening the 
dura mater, the whole, or nearly the whole of the convex surface of both 
hemispheres, or in some cases only one, are found to be covered with a 
yellowish or greenish-yellow layer, which consists of fluid or concrete pus, 
or of false membranes. These deposits exist also on the internal surfaces 
of the hemispheres, on the upper surfaces of the cerebellum, and often 
also at the base of the brain, though, in some cases the latter presents 
none whatever. These inflammatory products are seated in the pia 
mater, and sometimes in the cavity of the arachnoid membrane, but in 
much smaller quantity than in the tissue beneath that membrane. 

The arachnoid membrane which covers the brain seldom participates 
in the inflammation, but remains smooth and transparent. Its cavity, 
however, often contains inflammatory products, which, when death occurs 
early in the attack, consist of a small quantity of pure pus, or of larger 
quantities of a turbid, yellowish serosity, consisting of serum and pus 
mixed together. "When death has occurred later in the disease, — after 
five, six, or seven days, — the pus is found converted, by the absorption of 
its fluid particles, into a solid substance, or else true false membranes are 
found. The pia mater is observed to contain fluid or semi-fluid pus, when 
death occurs before the fourth or fifth day, while at a later period the pus 



400 SIMPLE MENINGITIS. 

has become hardened, so as to form a layer, which sometimes dips into 
the anfractuosities, and gives to the membrane under consideration a 
swelled and thickened appearance. These appearances are more marked 
on the superior and lateral, than on the inferior surface of the brain. 
Where the deposits exist the membrane presents a vivid injection, which 
is more marked in proportion as death has taken place earlier in the 
disease. The pia mater is generally easily detached from the cerebral 
substance, particularly when the fatal termination has occurred early. 
The substance of the brain is firm, and but slightly colored, in rapid cases. 
When the course of the disease has been slower the cineritious portion is 
generally of a bright rose color, and the medullary substance abundantly 
dotted with red. In the latter class of cases the surface of the convolu- 
tions is sometimes softened, and the pia mater adherent. In very young 
children, the whole brain is sometimes soft. 

The ventricles do not, as a general rule, contain transparent serum, 
except at a very early age, when serous effusion takes place with great 
facility. They often, however, contain one or two teaspoonfuls, and rarely 
more than one or two tablespoonfuls, of pus or purulent serum. The 
serous membrane of the ventricles and the plexus choroides exhibit signs 
of inflammation in some instances. They are of a bright red color, 
uneven, rough, and very much softened, in children who die early ; and 
pale, opaque, slightly thickened and rough, in those who die at a later 
period. 

The central parts of the brain often retain their firmness, but are some- 
times softer than natural, or even diffluent'. This softening is particu- 
larly apt to exist in very young children, in connexion with large effusion 
into the ventricles ; though it also occurs in those who are older, and in 
whom there is only slight effusion of pus or purulent serum. In the 
former case it is probably due to the macerating effect of the effusion, 
while in the latter it is more likely to be owing to inflammation. 

The spinal marrow was examined in one case by M. Legendre, and its 
membranes found to present the same inflammatory appearances which 
existed in those of the brain. 

The other organs are healthy except in secondary cases. Tubercles, 
which so constantly exist in various other organs in tuberculosis of the 
meninges, are never found, according to M. Rilliet, in this form of menin- 
gitis. This author believes himself entitled from his researches to formu- 
late the following law of pathological anatomy : " That general meningitis 
and meningitis of the convexity of the brain occur Only in non-tuberculous 
children, whilst meningitis of the base of the brain, without inflammation 
of the lining membrane of the ventricles, belongs exclusively to tubercu- 
lous children." (Loc. cit., t. iii. 1846, p. 408.) 






SYMPTOMS. 401 

Symptoms. — The following account of the symptoms of the disease is 
taken chiefly from the paper of M. Killiet. That author describes two 
forms of the affection, the convulsive and phrenitic ; the former of which 
is characterized by a predominance of convulsive phenomena, and the latter 
by disorders of the intelligence. 

The disease may also be idiopathic or secondary, simple or compli- 
cated, sporadic or epidemic. 

The convulsive form generally occurs in children under two years of 
age. The disease usually begins suddenly or after a restless night, with 
a violent and prolonged-attack of convulsions, oftener general than partial, 
and is accompanied by violent fever, and sometimes by considerable quick- 
ness of respiration. The existence of headache cannot be ascertained at 
this early age. Vomiting is often absent, and the bowels generally con- 
tinue regular in this form, though they are sometimes constipated. After 
a while the convulsions cease, and the child remains for the time in a 
state of quiet, somnolence, or coma, when they return with renewed vio- 
lence. The returns of the convulsions generally take place at intervals of 
one or two hours or longer. In the intervals between the crises the child 
is restless or drowsy, or in a state of partial stupor, attended with tremu- 
lous movements of the extremities; there is strabismus, contraction of the 
pupils, trismus, and sometimes hemiplegia. The skin retains its warmth, 
the pulse is accelerated, irregular, and unequal; the face is pale; the 
stools are spontaneous or easily procured by remedies. It is unusual to 
see the child regain its consciousness so as to recognise objects in the in- 
tervals between the convulsions, or after the appearance of coma and other 
cerebral symptoms. Death occurs during coma or in a violent attack of 
convulsions. This form seldom lasts more than four days. 

M. Rilliet states that this form sometimes begins in a different manner. 
The convulsions, though they still predominate, do not occur until later 
in the disease, and the whole course of the affection is slower. Such cases 
begin with a violent febrile movement, lasting several days, and accom- 
panied by acceleration or unevenness of the respiration, or by almost con- 
stant drowsiness, preceded or followed by agitation, screaming, staring 
expression of the eyes, and dilatation of the pupils ; vomiting and consti- 
pation are sometimes present, at others absent. After a time, however, 
convulsions make their appearance, and the case follows the course already 
described. The duration of this form may be the same as that of the first, 
or it may last about two weeks. 

The phrenitic form of simple meningitis generally begins suddenly 
with fever, which is sometimes preceded by a chill ; the skin is warm and 
dry, and the pulse, in idiopathic cases, full and accelerated. In secondary 
cases the pulse has been found slow and irregular ; in all it becomes irre- 

26 



402 SIMPLE MENINGITIS. 

gular, small, and very rapid, the day before death. Simultaneously with 
the fever there is frontal headache, which is often so violent as to draw 
cries from the child, and, according to M. Rilliet, is more severe than 
either in tubercular meningitis or typhoid fever. It is also more con- 
stant, and lasts generally one, two, or three days, until the appearance of 
restlessness, delirium, or coma. At the same time there is great sensi- 
bility to light and noise, and abundant vomiting of bilious matter. The 
latter symptom is one of the earliest ; it generally ceases after a few days, 
but sometimes continues to the very end. Constipation exists in some 
cases, but is much less constant and more easily overcome than in the 
tubercular disease. The appetite is lost, and the thirst very acute. The 
abdomen is flattened and retracted, especially towards the termination, 
while in secondary cases of this form, and in very young children, it 
retains its usual shape. 

About the end of the first day, generally, or in rare instances, after two 
or three days, appear various disorders of the intelligence. The first 
symptom of this kind is observable in the expression of the face, which 
becomes a little wild or wandering, and sometimes grimacing. Soon 
afterwards occur restlessness, which is sometimes extreme, and, in succes- 
sion, delirium, somnolence, and later in the attack, coma. The restless- 
ness and somnolence often alternate early in the case, though the former 
generally predominates and soon passes into delirium, which is usually 
violent. When in this condition the child seldom recognises any one, 
and either refuses to answer questions, or answers incoherently. In con- 
nexion with the disorders of intelligence there exist also trismus, grinding 
of the teeth, subsultus tendinum, partial convulsive movements, stiffening 
of the extremities or trunk, retraction of the head, strabismus, contraction 
first and then dilatation of the pupils, and in some cases violent convul- 
sions, followed by deep coma. Death sometimes occurs at this period. 
In other instances, the disease continues longer, and other symptoms 
declare themselves. Vomiting generally ceases ; constipation increases; 
the abdomen is retracted ; headache is no longer complained of; the fever 
continues, but the pulse becomes irregular ; the respiration is uneven and 
irregular, being sometimes more and at others less frequent than natural ; 
the face is distorted and extremely pale, or there may be a purple flush 
on the cheeks ; the restlessness is excessive, and accompanied by sub- 
sultus, carphologia, or partial convulsive movements; the delirium, at 
first so violent as to make it necessary sometimes to hold the child in 
bed, subsides into a state of coma and collapse, in which general sensi- 
bility is obtunded, and special sensibility extinguished ; the respiration 
becomes stertorous, and at length asphyxia, coma, or a severe attack of 
convulsions terminates the scene. 



DIAGNOSIS. 403 

The course of the disease is generally continuous. In very rare cases, 
however, occasional remissions occur, so that the child recovers its intel- 
ligence for a short time, and recognises persons around. The duration 
has varied between a day and a half and nine days. 

Diagnosis. — The convulsive form may be confounded with the essential 
or symptomatic, and with the sympathetic convulsions of children. The 
mistake may generally be avoided by attention to the following points. 
In essential convulsions, the attacks are usually less violent, seldom last 
more than a few moments, occur from some evident cause, and do not 
recur often. When they have ceased, the child generally soon regains 
its consciousness and health, or exhibits slight drowsiness, or derangement 
of movement for a short time only. In such cases the respiration is not 
permanently accelerated, as in convulsive meningitis ; the pulse, if it had 
been increased in frequency, soon falls to the natural standard, and 
special sensibility remains undisturbed. 

It is to be distinguished from sympathetic convulsions by the cha- 
racters just described, aided by a reference to the disease which may have 
caused the attack of eclampsia, and which may be one of the eruptive 
fevers, enteritis, indigestion, pneumonia, or any other acute affection. In 
some instances, however, the distinction cannot be made except by atten- 
tion to the progress of the attack. 

The phrenitic form may be confounded with tubercular meningitis, with 
congestion of the brain, or with the early stage of the eruptive fevers. 
The distinction between it and tubercular meningitis has already been con- 
sidered under the head of the latter disease. 

M. Rilliet is of opinion that it is sometimes impossible, in the present 
state of knowledge upon these points, to distinguish with certainty between 
simple meningitis and cerebral congestion or hemorrhage, and encephalitis. 
In regard to congestion of the brain, he proposes the very important ques- 
tion, " Whether we ought to class as meningitis the dangerous cerebral 
symptoms resembling exactly those which mark the commencement of 
meningeal inflammation, and terminating rapidly by death or recovery f" 
He states that examination after death in these cases reveals neither pus 
nor false membranes in the arachnoid or pia mater, but simple congestion 
of the brain and its membranes. He deems the solution of the question 
to be difficult, but is himself of opinion that they ought not to be classed 
together. He gives the following table, which he thinks may assist in 
making the diagnosis. 



404 SIMPLE MENINGITIS. 

CONGESTION OF THE BRAIN — MODE OF MENINGITIS. 

INVASION. 

There occurs instantaneously pro- In the phrenitic form the first symp- 
found stupor, absolute immobility and torn is generally headache, which is not 
insensibility, with dilatation of the pu- noted in any of the cases of M. Bland 
pils ; or else acute delirium, with diffi- (of congestion). The alterations of in- 
culty of breathing, and with accelera- telligence and movements occur early, 
tion and smallness of the pulse ; or in but not before the beginning of the first 
yet another class of cases with tremors or second day; whilst in congestion, the 
or slight convulsive movements of one appearance of delirium or coma, of sub- 
side of the body. Stuttering, loss of sultus tendinum, or partial paralysis, is 
speech, stertorous respiration and pains instantaneous, frightful, truly apoplec- 
in the arms and corresponding side of tic, and, so far as we can ascertain, not 
the face exist ; the fingers do not retain accompanied by vomiting, — a symptom 
objects which the child attempts to grasp, rarely absent in meningitis. 

From the invasion of variola, it is to be distinguished by attention to 
the contagious and epidemic nature of that malady, by the absence of vac- 
cination or of a prior attack of the disease, by the absence of pains in the 
loins, and by a consideration of the period at which the delirium makes 
its appearance, which, in variola, rarely occurs before the third day. To 
make the diagnosis between meningitis and malignant scarlatina, we must 
attend chiefly to the epidemic and contagious character, to the thick coat- 
ing upon the tongue, redness of the throat, elevated temperature, and 
strong nasal respiration, which exist in the latter. 

Prognosis. — The prognosis of simple meningitis is very grave. M. 
Yalleix is disposed to think that most of the recoveries reported by M. 
Guersant were cases of sanguine congestion or effusion. M. Rilliet (Loc. 
cit.), who has studied the subject more carefully than any other observer, 
cites several instances of recovery, but states that death is much the most 
frequent termination. The diagnosis of the disease from other cerebral 
affections, is so difficult and uncertain, at present, however, as to render it 
impossible to determine with any certainty, its degree of curability. 

Treatment. — It must be evident, it seems to me, that but little depen- 
dence can or ought to be placed on any but the most powerful antiphlo- 
gistic treatment. Bloodletting, therefore, mercury, cold applications to 
the head, purgatives, counter-irritants, and the most rigid diet ought to 
be employed from as early a period as possible, and in the most energetic 
manner. 

Venesection ought always to be preferred to local bleeding, even in the 
youngest children, unless it is impossible to find a vein, or unless this is 
evidently two small to bleed well. If we cannot succeed in performing the 
operation at the bend of the arm, we may resort to the vein running over 
the inner ankle, or to the external jugular. When venesection cannot, 



TREATMENT. 405 

from any reason, be employed, blood should be freely drawn by means of 
leeches or cups. It is customary to apply the leeches to the temples or 
behind the ears. I may remark that MM. Pulliet and Barthez object to 
the application of leeches to the head, and propose that they should be 
placed rather about the anus, or on the inferior extremities. The quantity 
of blood to be drawn must depend upon the age and constitution of the 
child, and the violence of the attack, in some measure. It should always, 
however, be large, as much, or more, I think, than what is necessary in 
any of the acute affections of childhood. In a child two years old, of 
good constitution, from four to six ounces would not be too much at first, 
and should the symptoms not be moderated in six or eight hours, as much 
more may be taken. Should these detractions of blood fail to produce 
any good effect upon the dangerous symptoms, I would, unless there were 
evident and unmistakable signs of exhaustion, take still more, either 
locally or generally. I am disposed to believe that in such a disease as this, 
bleeding is by far the most powerful remedy, and it is perhaps the only 
one which offers us any real chance of success, at least in rapid cases, in 
which extensive layers of fluid or partially concrete pus and false mem- 
branes are found on the surface of the brain, in the pia mater, or in the 
sub-arachnoid tissue, in two days and a half, in three, or in four days after 
the commencement of the disease. I once took four ounces of blood from 
a child five weeks old, who was laboring under convulsions and insensi- 
bility, occurring in the course of lobular pneumonia, and the child reco- 
vered. In another of the same age, with convulsions from congestion of 
the brain, or possibly from the very disease we are now considering, I re- 
moved four ounces in twelve hours by venesection and leeching ; in an- 
other of seven months, with repeated convulsions, lasting with slight 
intervals for ten hours, and followed by nearly complete paralysis of the 
left arm, I took seven ounces in that time ; both recovered and were not 
permanently injured by the loss of blood. I have taken between fourteen 
and fifteen ounces of blood by venesection- from a child two years old, 
attacked with pseudo-membranous laryngitis, in two days, and fourteen 
from another four years old in the same time, for the same disease, and 
.they both recovered without any injury to their constitutions. I men- 
tion these amounts in order to show that children laboring under acute 
and dangerous inflammations of important organs, bear large detractions 
of blood without injury, and because I know that there is a strong 
feeling amongst many members of the profession in this city against co- 
pious bleedings in childhood under any circumstances. 

While the bleeding is being performed we should direct the preparation 
of means for the application of cold to the head, which constitutes accord- 
ing to all writers, a most efficient remedy in inflammations of the brain 



406 SIMPLE MENINGITIS. 

and its membranes. These may consist of a bladder containing water and 
pounded ice, which is perhaps the most convenient and powerful, of cloths 
wrung out of iced or very cold water, to be constantly renewed, of cold 
affusions upon the head, or, lastly, of irrigation as recommended by M. 
Guersant, and described in the article on tubercular meningitis. Purga- 
tives ought to be employed so as to empty the bowels thoroughly and 
produce a decided revulsion upon the intestinal mucous membrane, but 
not in such quantity as to occasion inflammation of that tissue, which 
would be very apt to prove the case, were the drastic substances and large 
doses recommended by some writers, used. The remedy usually given 
and most highly recommended is calomel, which is chosen for its sedative 
and alterative properties. About four grains may be exhibited alone, and 
followed in one, two, or three hours by castor oil, jalap, or infusion of 
senna and manna, sweetened with syrup of rhubarb. These doses ought 
to be given until the bowels are freely moved. It is always useful to 
employ a strong purgative enema immediately after the bleeding, without 
waiting for the operation of the internal remedies. After the purgative 
doses have been given, it is important to continue the mercury in smaller 
quantities, with the view of obtaining its specific influence upon the inflam- 
mation. The doses may consist of from a quarter of a grain to a grain 
every hour or two hours. Some writers also recommend very highly the 
use of mercurial inunction. 

Counter-irritants are useful as adjuvants to the more powerful remedies 
already indicated. During the first day or two they should consist chiefly 
of sinapisms and mustard poultices applied from time to time to the trunk 
and extremities. Authorities differ somewhat as to the effect of blisters, 
and as to the time at which they ought to be applied. M. Valleix (Loc. cit. 
t. ix. p. 187), opposes their employment in this affection as often injurious 
and still more frequently useless. I believe that the advice given by Dr. 
Abercrombie as to their employment is probably the most prudent. This 
is not to apply them in the early stage, but to wait until the active symp- 
toms of the disease have been subdued. They may be applied to the 
head itself, to the nucha, or to the extremities. I believe that I have seen 
them most useful when applied to the neck and insides of the calves of 
the legs. Nevertheless, there is high authority in favor of their good 
effects when applied upon the head itself. 

M. Rilliet (Loc. cit.) recommends a vigorous revulsion upon the scalp 
when the disease has followed the suppression of an eruption. He pro- 
poses with this view the employment of pustulation by croton oil, and 
relates a case of recovery which followed this treatment under a most 
unfavorable train of symptoms. To make use of it the head must be first 
shaved; from fifteen to twenty drops of the oil are then to be rubbed over 



ACUTE HYDROCEPHALUS. 407 

the scalp with a glove, four or six times a day. Before making the fric- 
tion, the eyes of the patient must be covered with a band to prevent the 
introduction of any of the oil into them, as this would be apt to occasion 
severe ophthalmia. In the case reported by him a considerable number 
of pustules were produced in twenty-four hours, and in a few more the 
eruption was general, so that the head was covered with a kind of cap of 
a fine yellow color. 



ARTICLE III. 



YDROCEPHALUS. 



Under the term hydrocephalus were formerly included all the cases of 
disease of the brain attended with effusion of serum into the ventricles, into 
the cavity of the arachnoid or pia mater, or with infiltration of the cerebral 
substance. Recent observations have shown, however, as has already been 
stated in the two previous articles, that in the immense majority of cases 
the serous effusion within the cranium depends upon tuberculization of 
the membranes of the brain ; and that of the remaining cases the greater 
part are the result of simple meningitis, or of some other disease of the 
brain. In some few instances, however, effusion undoubtedly takes place 
independently of inflammatory action, and it is to these that the title of 
acute hydrocephalus is now generally applied. It ought to be observed, 
however, that the disease is almost always secondary, and that some 
writers, and amongst them MM. Gruersant and Blache, Valleix, and Rilliet 
and Barthez, without denying the possibility of the occurrence of idio- 
pathic cases, are evidently of opinion that they are extremely rare, and 
even that their existence may be doubted. 

Definition ; Synonymes ; Frequency. — By acute hydrocephalus is 
now generally understood, at least by the French writers, a disease in 
which a rapid but non-inflammatory effusion of serum takes place into the 
ventricles of the brain, and less frequently within the cavity of the arach- 
noid membrane, or through the substance of the brain. 

It has already been stated that under the title of acute hydrocephalus 
were formerly, and are yet by some persons, confounded, tubercular and 
simple meningitis, and indeed all acute lesions of the brain attended with 
serous effusion. 

It is an affection rarely met with in comparison either with tubercular 
or simple meningitis. It is denied by several high authorities to exist 
at all as an idiopathic disease, while all acknowledge it to be infrequent 
even in the secondary form. 



408 ACUTE HYDROCEPHALUS. 

Causes. — As even the existence of idiopathic acute hydrocephalus is 
doubted by many, and denied by not a few observers, its causes are of 
course but little understood. The cases of the disease met with, there- 
fore, are secondary. These may occur in the course of any disease 
liable to be complicated with anasarca, and particularly scarlet fever, 
measles, nephritis, gangrene, and entero-colitis. It is said to occur gene- 
rally under six years of age, and equally in both sexes. 

Anatomical Lesions. — MM. Rilliet and Barthez state that they have 
rarely found more than from two to four ounces of serum in the ventricles, 
which are more or less dilated, and about the same quantity in the cavity 
of the arachnoid. The internal and external cerebral membranes, gene- 
rally pale or of their natural color, sometimes present a bright injection, 
thus showing the transition from simple dropsy to that which is the result 
of inflammation. The same authors describe the cerebral substance as 
healthy and natural, or as presenting more or less considerable punctua- 
tion or congestion. In some instances it participates in the dropsy, and 
the parts adjoining the effusion are softened and of a creamy consistence. 
This is particularly observable in the walls of the ventricles when the 
serum has been effused into those cavities. 

Symptoms. — The symptoms of acute hydrocephalus, like the rest of the 
history of the disease, are very imperfectly understood. MM. Rilliet and 
Barthez, with Guersant and Blache, are of opinion that it is difficult and 
even impossible to establish any characters which indicate the presence of 
acute hydrocephalus. The only symptoms they have been able to refer to 
it are excessive agitation, cries or constant moaning, replaced a short time 
before death by extreme prostration with somnolence, loss of conscious- 
ness and coma, or even general insensibility, dilatation of the pupils, and 
fixity of the look. 

M. Barrier states that the disease appears under two different forms. 
In the first, the effusion taking place gradually, the symptoms are very 
analogous to those of the invasion of meningitis, and are characterized by 
phenomena of excitation, such as headache, delirium, restlessness, scream- 
ing, and convulsive movements. This period lasts from a few hours to 
several days, but very rarely so long as the first and second stages of acute 
meningitis united. In the second period of the first form of hydroce- 
phalus now under consideration, the preceding symptoms give place to 
abolition of the intelligence and senses, to coma, amaurosis, deafness, in- 
sensibility of the skin, and cessation of all voluntary movements. The 
latter symptom, however, is not constant; for it often happens that violent 
convulsions occur in the midst of the state of collapse. 

In the second form of hydrocephalus, the first period above described is 
wanting, and the phenomena of the second period appear from the first. 



DIAGNOSIS — PROGNOSIS — TREATMENT. 409 

This form might with some propriety be called serous apoplexy. It 
is particularly apt to occur in the course of the anasarca of scarlet 
fever. 

The diagnosis of acute hydrocephalus is, as might be supposed from the 
uncertainty of the symptoms, enveloped in much obscurity. I will merely 
quote the statement by M. Valleix, that if, in the course of a dangerous 
disease, and particularly in the anasarca which follows scarlet fever, severe 
cerebral symptoms without paralysis are observed to occur, we may suspect 
the existence of acute hydrocephalus j the presumption would be still stronger 
and would amount, indeed, almost to a certainty were a more or less rapid 
loss of consciousness observed to follow the disappearance of a serous 
effusion situated in some part of the body more or less distant from the head. 

The prognosis is exceedingly unfavorable, as the disease rarely occurs 
except in the course of, or at the termination of other affections which are 
themselves very dangerous to life. 

Treatment. — The treatment of acute hydrocephalus is rendered very 
uncertain in consequence of the obscurity of the diagnosis. Bloodletting, 
however, has been employed in several cases, and apparently with good 
effects in some which occurred in the course of diseases of a manifestly 
dropsical character. Such was the case reported by Dr. M. Hall (Dis. 
and Derange. Nerv. Syst. p. 152,) which occurred in a boy twelve years 
old, on the sixteenth day after the invasion of scarlet fever, and came on 
simultaneously with oedema of the face, by a sudden attack of collapse, 
followed by convulsions and coma. Dr. Hall bled the child to the amount 
of twenty ounces from the jugular vein, when the convulsions ceased, 
but the coma did not disappear. He then took seven ounces more from 
the arm, and in less than an hour the child knew his parents. The case 
terminated favorably. A case is reported by M. Barrier (Loc. cit. t. ii. 
p. 359), from a memoir on acute hydrocephalus by M. Piet, of a girl nine 
years old, who, on the fifteenth day of a very mild attack of scarlet fever, 
took cold in the evening from exposure at an open window, and was at- 
tacked the next day with tonsillitis, oedema of the face, and then with 
amaurosis, complete immobility of the pupils, violent convulsions of the 
right side, palpitations, and stupor. She was treated by leeches to the 
head, tartar emetic, powdered digitalis, and diuretic infusions. After five 
days the oedema and nervous system began to moderate, and in a short 
time she was restored to health. 

M. Barrier relates another case published by M. Lecointe, of a boy 
thirteen years old, who, about two weeks after an attack of some erup- 
tive disease, which was almost certainly scarlet fever, was seized with 
oedema of the feet, legs, scrotum, and abdomen, and with headache. After 
a short time he was attacked with violent epileptiform convulsions, intense 



410 ACUTE HYDROCEPHALUS. 

headache, and soon after with loss of sight and hearing, and stupor. The 
convulsions were frequent, and while they lasted the face became purple, 
and the mouth filled with bloody spume ; the contortions were terrible. 
On the first day he was freely leeched along the jugular veins, a camphor- 
ated blister was applied upon each thigh, and an emollient cataplasm upon 
the abdomen. He took internally a mucilaginous drink containing nitre, 
and ten drops of sulphuric ether in water every hour. On the second day 
the condition remained the same ; pupil excessively dilated, pulse hard and 
accelerated : venesection to about sixteen ounces. An hour later, as the 
convulsions returned, about twelve ounces more of blood were taken in the 
same way. In the course of the day, the bandage around the arm got 
displaced ; this was not discovered for several hours, so that a considerable 
hemorrhage took place, but the convulsions did not return afterwards. 
From that moment the patient recovered gradually under the use of 
sinapisms to the extremities, a potion composed of the tinctures of castor 
and amber, and sulphuric ether, and a drink made of infusion of cherry- 
laurel and orange flowers. On the third day he recovered his sight and 
entire consciousness, and on the eighth day was able to walk. 

That bleeding does not always produce such good effects, however, is 
shown by the result of the following case which occurred to myself. An 
unusually large and hearty girl, twelve years old, was seized with grave 
scarlet fever, of which she was extremely ill from the third to the ninth 
day. She then improved somewhat, but on the twelfth day was attacked 
with general anasarca, unaccompanied, however, with severe nervous symp- 
toms, and which nearly disappeared on the sixteenth. From the twenty- 
first to the twenty-fifth day, she did very well. There was merely slight 
oedema of the face, and she sat up the greater part of the day in good 
spirits. At eight o'clock, on the evening of the twenty-fifth day, as she 
sat in an armchair, taking her tea, she said suddenly to her sister, " there 
is some one sitting on my arm," and her sister saw that on endeavoring to 
take hold of a teaspoon, the hand no longer obeyed the will. Her speech 
then became mumbling, and she fell back in a slight convulsion. I saw 
her within half an hour from the beginning of the attack, and found her 
unable to speak, almost insensible, and slightly convulsed. I bled her 
immediately to the amount of twenty ounces from the arm, applied cold 
to the head, gave a purgative enema, and ordered a cathartic dose of 
calomel and jalap. In a few moments after the bleeding she was attacked 
with terrific general convulsions. The bleeding was repeated in half an 
hour to the amount of at least sixteen ounces more, but without any effect. 
The convulsions continued with very slight intermissions for ten hours, when 
they ceased, and were followed by profound coma and death in twenty- 
three hours from the onset of the nervous symptoms. No autopsy was 
made. 



CEREBRAL CONGESTION. 411 

I have only to add, in regard to the treatment of acute hydrocephalus, 
the advice of M. Barrier, which is to employ, when the apoplectic nature 
of the disease, its coincidence with dropsical affections of other parts of 
the hody, the state of the urine, and the antecedent history of the case, 
make the diagnosis clear, the treatment generally required by scarlatinous 
dropsy, that is to say, diaphoretics, diuretics, and hydragogue cathartics. 
He adds that as experience has seemed to show that bloodletting is useful, 
though hydrocephalus is not probably an inflammatory disease at first, we 
should be blamable not to resort to it. For further information on this 
subject, the reader is referred to the article on scarlet fever. 



ARTICLE IV. 



CEREBRAL CONGESTION. 



It appears to me from the evidence of several of the highest authorities 
on the diseases of children, that cerebral congestion is of rare occurrence 
as an idiopathic and distinct affection in early life. To prove the truth of 
this statement I have only to quote the opinions of some of the writers 
referred to. MM. Rilliet and Barthez assert (t. i, p. 649) that they have 
found in children dying of different diseases, and who had presented no 
cerebral symptoms, congestion precisely similar to what they found in 
others, who had exhibited more or less dangerous idiopathic or secondary 
nervous symptoms. " Some patients," they remark (Xoc. cit. p. 650), 
" it is true, who presented us with examples of cerebral hypersemia, had 
had well-marked nervous symptoms. Thus we have met with the anato- 
mical characters of congestion in young subjects who had perished with 
convulsions, in those whose sickness had been accompanied by violent de- 
lirium, and in others who, in the course of scarlet fever, for instance, had 
been seized with nervous symptoms. But, on the other hand, we have 
met with a nearly equal number of patients who had died under the same 
circumstances, but in whom the cineritious and medullary substances pre- 
served their usual color, and the pia mater was not injected. What are 
we to conclude from these facts ? Most assuredly that we ought not to 
attribute to cerebral hyperseniia any considerable part in the production of 
the symptoms." At page 651 they say : " The most important practical point 
is, in fact, to determine whether it is possible to recognise cerebral con- 
gestion in a child by special and characteristic symptoms, and whether we 
ought as a consequence to prescribe a particular form of treatment. We 



412 CEREBRAL CONGESTION. 

acknowledge, on our part, that we find it impossible to describe any symp- 
toms peculiar to that condition, and consequently to formulate a treat- 
ment." In the article on convulsions (t. ii. p. 281) they state that in 
some of their patients they found no traces of congestion, and add that 
eclampsia is sometimes (a well-known fact) connected with an anaemic 
state of the brain. " What are we to conclude from these opposite facts, 
if it be not that congestion plays but a secondary part in convulsions ?" 
They coincide in opinion with the authors of the Compendium, who sup- 
pose that the congestion found in patients who have died with convulsive 
symptoms, is generally the effect and not the cause of the convulsions. 
They do not deny, however, that a sudden congestion of the brain may 
produce a convulsive attack, and quote cases from other writers. 

I believe it to be a very common opinion in this country that most of 
the nervous symptoms (delirium, somnolence, coma, convulsions, &c), 
which occur in the course of many of the diseases of childhood, depend 
chiefly upon a congested condition of the nervous centres, and many practi- 
tioners, I believe, also, refer most of the cases of eclampsia of children to the 
same cause. I am glad, therefore, to call the attention of the profession 
to this point, and to place before it the opinions of some of the recent dis- 
tinguished authorities in regard to it. 

The authors of the Biblioiheque du Med. Prat, are of opinion that it is 
very rare to meet with true pathological and idiopathic congestion of the 
brain, either in the first or second infancy (t. vi. p. 118). M. Barrier 
states that primary or secondary hyperemias are sometimes a cause of 
convulsions, and that such cases are the most dangerous of their kind. 
He also states that in rare instances congestion assumes a more menacing 
character, similar to that which is more frequently met with at an ad- 
vanced age, meaning the apoplectic form. M. Valleix asserts {Loc. cit. 
t. ix. p. 259) that " cerebral congestion is a disease almost unknown in 
infancy." 

M. Rilliet, in the paper on simple meningitis quoted in the article on 
that disease, states as his opinion that the cases attended with dangerous 
cerebral symptoms, which resemble exactly those occurring at the com- 
mencement of meningeal inflammation, which terminate rapidly in death 
or recovery, and in which the only lesions found after death are congestion 
of the brain and its membranes, ought to be regarded as dependent upon 
congestion, though he thinks it difficult to determine positively whether 
they are in fact the result of that condition, or whether they are not 
merely the forming stage of meningitis. 

J)r. Chas. West, of London, whose recent publications upon the diseases 
of children are the most valuable, it seems to me, that the English press 
has afforded us, treats of congestion of the brain in children as a very 



GENERAL REMARKS. 413 

important and frequent condition of disease. {Led. on the Bis. of Inf. 
and Childhood, Lond.) I shall chiefly follow Dr. "West in my remarks 
upon this subject, for though there can be no doubt, from the researches 
of the French observers above quoted, that its importance has been much 
exaggerated, and that its real influence in the production of the symptoms 
generally ascribed to it is very imperfectly understood, yet a considerable 
number of cases occur in practice, especially favorable ones, which it is very 
difficult to understand or to know how to treat except upon the time- 
honored supposition of congestion. 

Dr. West treats of congestion of the brain under two heads, as active or 
passive. By the former is meant the kind of congestion occurring under 
the influence of a cause which greatly increases the flow of blood to the 
head, and to this class belong, for instance, the head symptoms which often 
usher in the eruptive fevers ; by the latter is understood the kind depend- 
ing on an impediment to the reflux of blood from the brain, to which 
belong, for example, the convulsions which occur in a fit of hooping-cough. 

Active congestion may occur during the process of dentition, or may result 
from exposure to the sun, or from blows upon the head : passive congestion 
may be the result of a mechanical impediment to the return of blood from the 
brain, as the pressure of an enlarged thymus, or it may be the result of en- 
larged and tuberculous bronchial glands upon the jugular veins, or of languid 
circulation depending upon want of pure air, or of nourishing and sufficient 
food. Dr. "West states that intense cerebral congestion is not a very un- 
usual consequence of the disturbance of the circulation at the outset of the 
eruptive fevers. He says that convulsions and apoplectic symptoms some- 
times come on suddenly in these cases, and may terminate fatally in less 
than twenty-four hours : after death " the brain is found loaded with blood, 
but all the other organs of the body are quite healthy. " I would merely 
remark here, that it seems to me very doubtful whether the nervous 
symptoms just alluded to, ought not to be regarded as the result of the 
presence in the nervous centres of a diseased and vitiated blood, rather 
than of congestion. That congestion does not always produce them is 
shown by the statement of MM. Rilliet and Barthez (Loc. cit. t. ii. p. 
620), in regard to the cerebral symptoms of scarlet fever, " that a more or 
less marked sanguine congestion (of the cerebro-spinal apparatus) is the 
only alteration generally but not always found ; and sometimes the conges- 
tion is not more marked than in other diseases in which there had been no 
cerebral symptoms." With these remarks I shall pass on to the conside- 
ration of the symptoms generally ascribed to congestion occurring under 
other circumstances, as those taking place in the course of the eruptive 
fevers will be treated of under the head of those affections. 

Dr. West states that cerebral congestion may come on suddenly with 



414 CEREBRAL CONGESTION. 

very alarming symptoms, or it may be preceded for a few days by general 
uneasiness, by a disordered state of the bowels, generally but not always 
consisting of constipation, and by peevishness. " The head by degrees 
becomes hot, the child grows restless and fretful, and seems distressed by 
light, or noise, or sudden motion, and children who are old enough some- 
times complain of their head." Vomiting generally occurs repeatedly, 
sometimes before any other symptoms, and is a very important sign. The 
fever varies greatly as to its violence, though the pulse is usually much 
and permanently quickened, and if the skull be still unossified, the an- 
terior fontanelle is either tense and prominent, or the brain is felt and 
seen to pulsate forcibly through it. The sleep is disturbed, the child often 
waking with a start, and there is often occasional twitching of the muscles 
of the face or the tendons of the wrist. 

The child, Dr. W. remarks, may recover from these symptoms without 
any medical interference, or the case may become aggravated and terminate 
in acute hydrocephalus; or again, the congestion may increase and cause 
the following symptoms. Under the latter condition, u the countenance 
becomes heavy and anxious, the indiiference to surrounding objects in- 
creases, and the child lies in a state of torpor or drowsiness, from which, 
however, it can at first be roused to complete consciousness." The bowels 
generally continue constipated, and the vomiting seldom ceases, though it 
may be less frequent. The pulse is usually smaller than before, and often 
irregular in its frequency, though not intermittent. "An attack of con- 
vulsion sometimes marks the transition from the first to the second stage; 
or the child passes, without any apparent cause, from its previous torpor 
into a state of convulsion, which subsiding, leaves the torpor deeper than 
before. The fits return, and death may take place in one of them, or the 
torpor growing more profound after each convulsive seizure, the child at 
length dies comatose." 

This second stage is usually of short duration, as death generally 
occurs, unless relief be afforded by appropriate treatment, within forty- 
eight hours from the first fit, " though no graver lesion may be discovered 
afterwards than a gorged state of the vessels of the brain and its mem- 
branes, and perhaps a little clear fluid in the ventricles and below the 
arachnoid." Occasionally, however, recovery takes place contrary to all 
expectation, after these symptoms have continued but slightly modified, 
for days or even weeks. 

Acute congestion is to be treated like simple meningitis, with blood- 
letting, cathartics, calomel, cold applications to the head, baths, revul- 
sives, low diet, and confinement to a cool, dark chamber. It is useless to 
repeat here, what has already been said in our remarks upon the treatment 
of meningitis. 






CEREBRAL HEMORRHAGE. 415 

In passive congestion the treatment should consist, according to Dr. 
West, of careful local depletion, if the case will bear it, and in strict 
attention to the diet and state of the bowels. He recommends mercury 
and chalk to correct the bowels when they are out of order. If the case 
be associated with diarrhoea and bad nutrition, he recommends that extract 
of bark, with a few drops of sal volatile, or of the compound tincture of 
bark, be given two or three times a day. Farinaceous food, he remarks, 
is not usually well digested when nutrition is much impaired, and he 
recommends milk and water, or milk and water with isinglass, or veal tea. 



ARTICLE Y. 



CEREBRAL HEMORRHAGE. 



I shall consider hemorrhage of the brain under two heads, that of the 
substance, and that of the membranes j the former is usually desig- 
nated as cerebral, and the latter as meningeal apoplexy. Both these 
forms of hemorrhage are of rare occurrence in childhood compared with 
other diseases of the brain, and with their frequency during adult life and 
old age. Of the two kinds, that of the meninges is the most common. 
I desire to state, before beginning the consideration of this subject, that 
I do not expect to be able to give an accurate account of it, since this is 
impossible in the present state of knowledge in regard to the diseases of 
children. I shall endeavor, however, by careful examination of receut 
authorities, to present as faithful a picture as is possible under existing 
circumstances. 

Definition ; Frequency ; Forms. — By cerebral apoplexy or hemor- 
rhage is understood an effusion of blood into the substance of the brain. 
By meningeal apoplexy or hemorrhage is understood an effusion of blood 
between the dura mater and cranium, into the cavity of the arachnoid 
membrane, beneath the arachnoid, or in the meshes of the pia mater. 
Cerebral hemorrhage is a very rare affection in childhood. This is proved 
to be the case by the facts that MM. Rilliet and Barthez met with only 
eight cases in their extensive experience, and that M. Barrier saw but one 
in 576 cases of disease of all kinds. Meningeal apoplexy is of more fre- 
quent occurrence, since MM. Rilliet and Barthez report eighteen cases. 
M. Barrier met with one case of this form in the 576 cases referred to. 
Dr. West (Lond. Med. Gaz., June 18th, 1847, p. 1062), says he has only 
twice met with distinct extravasation of blood into the substance of the 
brain in. children. 



416 CEREBRAL HEMORRHAGE. 

Hemorrhage into the substance of the brain occurs in two different 
forms ; one in which the effused blood is contained in a cavity caused by 
a laceration of the tissue of the organ, and designated apoplexy in a cavity • 
and the other in which the blood is effused in a multitude of little points 
of different sizes, and designated capillary apoplexy. 
• In meningeal hemorrhage the blood may, as we have stated, be effused 
between the dura mater and the bone. This form, however, is very rare, 
so rare, indeed, that several writers deny its existence. It is proved, 
however, to have occurred, by a case reported by MM. Killiet and Bar- 
thez, which is the only one they have met with. In by far the most 
common form of the disease, the blood escapes into the cavity of the 
arachnoid membrane. Of this form the authors just quoted report 17 
cases, while, according to the authors of the Bibliotlieque du Med. Prat. 
(t. vi. p. 193), the effusion always occurs in this situation. That this is 
not invariably correct, however, is proved by the case of effusion exterior 
to the dura mater already referred to, and by the fact that it some- 
times takes place beneath or in the meshes of the pia mater. The latter 
class of cases is very rare, however, in proportion to those in which the 
hemorrhage occurs within the cavity of the arachnoid. MM. Rilliet and 
Barthez did not themselves meet with a single instance of that kind, but 
they quote two from other writers; and M. Valleix refers to a memoir 
by M. Prus, in which others are given. It appears, therefore, that in the 
great majority of instances, the exhalation takes place within the cavity 
of the arachnoid membrane. 

Causes. — The causes of cerebral hemorrhage are very obscure, so 
much so, indeed, that some writers have not attempted to ascertain them. 
They appear to be the same in both forms of the affection. Amongst the 
ascribed causes are the sudden disappearance of eruptions of the scalp, 
observed in two cases by MM. Rilliet and Barthez, in one of which this 
effect is stated to have been produced suddenly by medical treatment, 
while in the other it followed the application of poultices to a favous 
eruption upon the same part. The disease is stated by M. Legendre to 
have followed in one case a violent fit of anger. It is said also to have 
been produced by various causes which acted as impediments to the circu- 
lation. The obstacle may be situated within or exterior to the cranium. 
To the first class belong cases in which the sinuses and large venous 
trunks of the head have been found obstructed by coagula of blood, or 
by the pressure of tumors, generally of a tubercular nature; to the latter, 
those in which there is compression of the superior vena cava by enlarged 
and tubercular bronchial ganglions, or obstruction of the abdominal cir- 
culation by pressure of hypertrophied organs, and chiefly of the spleen or 
liver. Another cause is thought to be the existence of confirmed cachexia 



ANATOMICAL LESIONS. 417 

and general debility from any diseased condition whatever, in which the 
blood having become thin and lost its plasticity, escapes from the vessels 
with great facility. This last condition is one which almost always exists 
in connexion with the causes cited as acting through the agency of ob- 
struction to the circulation, and tends of course to augment their danger- 
ous effects. 

In some instances the hemorrhage occurs in the healthiest and most 
vigorous constitutions, and cannot be accounted for in any way. 

It appears that meningeal apoplexy is most frequently met with in 
very young children, according to MM. Billiet and Barthez, between the 
ages of one and two and a half years, whilst M. Legendre did not meet 
with a single case after three years of age in 248 autopsies. Cerebral 
and ventricular hemorrhage, on the contrary, are much more common 
after three years of age than before, which is just the reverse of the law 
in regard to meningeal effusion. 

Anatomical Lesions. — The description of the lesions of hemorrhage 
into the substance of the brain, need not detain us long, as they are much 
the same as those observed in the adult. When the blood is effused into 
cavities (apoplexy in cavities), the latter are usually small in size, seldom 
exceeding from one to two-thirds of an inch in diameter, though in rare 
cases they have been found much larger. The cavity is formed by a 
laceration of the substance of the brain, and is filled with soft, dark 
coagula, or sometimes with fluid blood; the walls of the cavity consist 
sometimes of the substance of the brain, which may be of a rosy color 
and natural consistence, or yellowish and softened, while in other instances 
they are formed of more or less numerous points of capillary apoplexy. 
The capillary form of effusion occurs in the shape of a number of points 
scarcely so large as the head of a small pin, and of a dark or brownish 
color, which contrasts strongly with that of the cerebral tissue. These 
points evidently consist of true coagula, which are sometimes surrounded 
by small yellowish areolae. The substance of the brain around the effu- 
sion is either white, firm, and perfectly healthy, or softened, and of a 
whitish, reddish, or yellowish color. The capillary effusions are generally 
limited within a space of from a third of an inch to an inch and a half 
in size, but have been found scattered over a large portion of the hemi- 
spheres, s 

Both forms of hemorrhage are much more common in the cerebrum 
than cerebellum, and occur more frequently on the left than right side. 
In addition to the sanguine effusion there is generally considerable con- 
gestion of the pia mater, of the venous sinuses, or of the substance of the 
brain itself. 

In describing the lesions of meningeal apoplexy, I shall confine my 

27 



418 CEREBRAL HEMORRHAGE. 

remarks to the effusion which occurs into the cavity of the arachnoid, 
this being, as we have already remarked, by far the most frequent form of 
the disease. 

The appearances presented by the cavity of the arachnoid into which 
the effusion has taken place vary greatly in different cases, according to the 
age of the child, the quantity of the exhalation, and the period of time which 
may have elapsed between the accident and death of the patient. It is 
very uncommon to find pure, liquid blood, though it has been met with. 
In most instances, there is a bloody serum mixed with thin, reddish 
coagula, contained in a soft and very delicate membrane lining the in- 
ternal surface of the arachnoid. Sometimes the effusion is thin, limpid, 
and more or less yellowish in color, while at other times it is thick and 
brownish, or chocolate colored. In some rare cases it is perfectly trans- 
parent and colorless. The fluid, in whatever state it exists, appears to be 
the result of transformations undergone by the effused blood. The solid 
portion of the blood or clot, is found either in the condition of more or 
less recent coagula, or changed into false membranes, which sometimes 
resemble very closely the arachnoid itself, and sometimes a true fibrous 
membrane. The coagula are found in the form of thin membranes, vary- 
ing between one or two lines, and an inch and a half or two inches in size. 
They are thickest generally in the centre, where they measure between a 
fifth of a line and two lines., and are brownish or greenish in color, and of 
variable consistence according to their age. These coagula may exist upon 
any portion of the brain, but according to MM. Rilliet and Barthez are 
most frequently met with upon its convex surface. 

The coagula just referred to undergo, in some instances, a curious 
change, of which I shall give a short description. In the course of time 
the fibrinous portions of the blood are deposited upon the internal surfaces 
of the cavity of the arachnoid, in the form of a new membrane. When 
death occurs soon after the onset of the attack, the parietal layer of the arach- 
noid is found to be completely lined with this membraniform production, 
whilst the visceral or cerebral layer is covered by it only in certain points. 
When the case has lasted a longer time, on the contrary, the visceral as 
well as parietal layer of the arachnoid may be covered with the new pro- 
duction, and when this happens there is formed a true sac or cyst, desti- 
tute of opening, which lines the whole interior of the arachnoid and contains 
within its cavity bloody serum and coagula. At first this new membrane is 
reddish in color, elastic, and of a stronger texture than might be supposed 
from its apparent thinness and softness. Its thickness is generally about 
a tenth of a line. At a later period the walls of the cyst become so thin and 
transparent, that they have been mistaken for the arachnoid itself. They 
differ, however, from the latter, in being rather less transparent and thin, 



ANATOMICAL LESIONS. 419 

and particularly in the circumstance of presenting numerous arborizations. 
When death occurs at this stage, which M. Legendre (whose description I 
chiefly follow) calls the second period, or that of complete organization of 
the cyst, the external surface of the latter is found to adhere intimately 
to the parietal portion of the arachnoid membrane, by very delicate cellu- 
lar tissue, though not with so much force but that it may be detached by 
traction. The internal portion of the new membrane, on the contrary, 
which is lubrified by the serosity of the arachnoid tissue, is very slightly 
adherent to the layer of that membrane covering the brain. 

So long as the cyst formed by the new membrane, or as it is called by 
MM. Rilliet and Barthez, the pseudo-arachnoid membrane, contains an 
amount of fluid sufficient to keep its surfaces separated, its cavity is single. 
When, on the contrary, the walls of the cyst have come into contact, 
either because of the partial absorption of the contained fluid, or because 
the fluid has accumulated at the lowest points, or wherever there is the 
least resistance, the cavity becomes multilocular in consequence of the 
cohesion of its walls at certain points. 

The size of the cyst varies exceedingly. Sometimes it covers the 
greater part of the convex surface of one hemisphere, sometimes the whole, 
while in other instances it extends to the base, forming in that case a nearly 
complete shell for the whole brain. The quantity of fluid varies in dif- 
ferent cases. Sometimes it amounts only to a few large spoonfuls; in 
others to one or two, or eight or nine ounces : in one case observed by MM. 
Rilliet and Barthez there was upwards of a pint on each side, or more than 
a quart in all. In most instances the hemorrhage occurs into both halves 
of the arachnoid membrane, so that there is a cyst for each hemisphere. 
More rarely it occurs only on one side. 

In the second stage, and when the effusion is very large, which rarely 
happens except in very young children and prior to ossification of the 
fontanelles or sutures, the symptoms resemble those of chronic hydro- 
cephalus. The vault of the cranium is enlarged by the unnatural promi- 
nence of the frontal and parietal bones ; the sutures are more open than 
usual, and the anterior fontanelle is distended and protuberant. When 
the effusion occurs thus early in life, before complete ossification of the 
skull, the brain does not appear compressed or flattened, as it does when 
the disease occurs at a later period. 

The visceral portion of the arachnoid is often thickened, opaque, and 
more resisting than natural. The pia mater is frequently infiltrated with 
a good deal of serosity, which sometimes has a gelatinous appearance. 
When death has occurred in the first stage of the disease, the brain usually 
presents signs of hypersemia. The veins on the surface of the hemi- 
spheres are enlarged, the cortical substance is of a bright rose-gray color, 



420 CEREBRAL HEMORRHAGE. 

and the medullary portion is dotted over with drops of blood. Sometimes 
the cellular substance beneath the arachnoid is slightly infiltrated with 
serosity, at other times not. The ventricles contain a very small quan- 
tity of fluid. 

It seems pretty clearly established that the effusion is the result of 
exhalations from the membrane, caused by frequently repeated determina- 
tions of blood to the head, independent of a rupture of vessels. In some 
rare instances, however, as in one witnessed by M. Legendre, the effusion 
is the result of rupture. In the case observed by him, death took place 
in twelve hours from the attack, and the left hemisphere was found 
covered with a layer of coagulated blood, which had escaped from a rup- 
tured vein. {Bibliotli. du Med. Prat., t. vi. p. 192.) 

Symptoms ; Duration. — The symptoms of hemorrhage into the sub- 
stance of the brain in the child are, as a general rule, extremely obscure 
and uncertain, though in some few cases that have been observed, they 
were as characteristic as those which occur in adults. In obscure cases 
the chief symptoms that have been noticed were restlessness, delirium, 
headache, violent fever, grinding of the teeth, and, after a time, complete 
abolition of the intelligence, fixity of the eyes, invariable dilatation of 
the pupils, stertorous respiration, and general insensibility. Of three 
cases reported by M. Valleix (Clinique des Mai. des Enf.*) the nature of 
the disorder was easily diagnosticated in one by the existence of complete 
hemiplegia, while in the two others, the only marked symptom was 
entire immobility. The only certain symptoms of the disease, there- 
fore, would be a sudden attack of hemiplegia, either as the primary 
symptom, or following coma or convulsions, and lasting for at least several 
days. An attack of general paralysis would not be by any means so 
certain, as this may exist in several other diseases of childhood. 

In a case which came under my charge, I believe the attack to have 
been one of apoplexy of this kind. A girl, two years and a half old, ap- 
parently in the enjoyment of excellent health, was suddenly, and without 
ascertainable cause, attacked with violent general convulsions and entire 
insensibility, which lasted with very slight remissions of the convulsive 
movements, but without any return of consciousness, for twelve hours. 
At the end of that time the convulsions ceased entirely, and she very soon 
regained her consciousness, remaining merely peevish and languid. She 
was, however, completely hemiplegic on the left side, so that she could 
neither rise in bed, nor turn towards the right side. The paralysis dimi- 
nished rapidly, but regularly, so that at the end of three days she could 
sit up in bed, and in a few weeks was perfectly well. This child remained 
well, with the exception of rather unusual excitability, and some peevish- 



SYMPTOMS. 421 

ness of temper, for three years, 'when she died of scarlet fever. No 
autopsy could be made. 

The obscurity which exists in these cases will be clearly understood by 
any one who will read two examples of this kind given by Dr. West. 
(Loc. cit. p. 1062.) 

With a short quotation from the work of MM. Rilliet and Barthez, I 
shall pass on to the subject of meningeal apoplexy. These authors re- 
mark (t. ii. p. 54), in speaking of this affection, that " cerebral symptoms 
have been observed to exist, but of so unusual a character, and so different 
from what have been assigned by writers to apoplexy, that they could not 
lead to a diagnosis of the disease." 

I shall describe the symptoms of the meningeal form of hemorrhage 
under two heads ; first, as they present themselves in the acute, and, second, 
as they occur in the chronic, or second stage of the affection. 

Unfortunately, the symptoms of the acute or first stage are not much 
more certain and distinct than those of cerebral hemorrhage. The disease 
may begin with fever, and some convulsive movements, or as happened in 
a case reported by M. Valleix, with violent general convulsions. Vomit- 
ing sometimes occurs at the beginning, but is usually very slight. It is 
difficult to know whether headache exists or not at the early age at which this 
disease commonly occurs. The convulsive movements generally affect par- 
ticularly the eyes, and are followed by some degree of strabismus. The 
appetite is lost from the first ; the thirst is moderate ; there is no constipa- 
tion. Soon after the symptoms just described, appear permanent contrac- 
tions of the hands and feet, which are followed by attacks of tonic or clonic 
convulsions, during which sensibility and intelligence are abolished. Be- 
tween the attacks of convulsions there is somnolence, which, though slight 
at first, becomes more marked as the case goes on. The attacks of con- 
vulsions become more and more frequent as the case progresses, until at 
the last they are nearly constant. The tonic convulsions affect the limbs 
and trunk both, but particularly the former, whilst the clonic spasms oc- 
cupy sometimes one side of the body, sometimes the upper extremity alone, 
and at other times the whole body, but even then are usually stronger on 
one side than on the other. Paralysis is rarely noticed in the disease ; it 
occurred only in one out of nine cases observed by M. Legendre, and in 
one out of seventeen observed by MM. Rilliet and Barthez. 

Dr. West remarks (p. 1061) : " The absence of paralytic symptoms, 
however, is not the sole cause of the obscurity of these cases, but the indi- 
cations of cerebral disturbance, by which they are attended vary greatly 
in kind as in degree. The sudden occurrence of violent convulsions, and 
their frequent return, alternating with spasmodic contraction of the fingers 
and toes in the intervals, appear to be the most frequent indications of the 



422 CEREBRAL HEMORRHAGE. 

effusion of blood upon the surface of the brain. I need not say, however, 
that such symptoms, taken alone, would by no means justify you in infer- 
ring that its effusion had taken place." Dr. West adverts particularly to 
the fact that apoplexy in the child is especially apt to occur in those 
who are weakly and feeble, and gives to this form of the disease the appel- 
lation of the cachectic form of cerebral hemorrhage. 

The chronic form presents most of the symptoms which exist in acquired 
chronic hydrocephalus from serous effusion into the ventricles. The cra- 
nium is very large in proportion to the face : the sutures are not ossified ; 
there is strabismus, with dilatation of the pupils ; the sense of sight is 
generally but not always retained ; the face loses its expression ; if the 
child was old enough at the moment of the attack to show signs of intelli- 
gence, the latter are found to diminish rather than increase, and some- 
times they are lost entirely, as the size of the head augments ; and the 
child is apt to utter loud cries, particularly during the night. The cuta- 
neous sensibility is in general neither lost nor diminished. The power of 
motion usually remains, though it was entirely lost in one case. The ap- 
petite and thirst persist. 

The duration of cerebral apoplexy is very irregular. In one case quo- 
ted by MM. Rilliet and Barthez, it was a quarter of an hour; in another 
an hour; in a third forty-eight days ; and in one reported by M. Valleix, 
in a very young infant, recovery was nearly perfect in a little less than two 
months when the child was seized with pneumonia and died. 

The duration of meningeal apoplexy is also irregular. According to 
M. Legendre, all the recent cases seen by him in the Children's Hospital 
died in from eight to twelve days, apparently rather from intercurrent 
diseases than from the primary affection itself, whilst cases occurring in 
subjects placed in better hygienic conditions, and not attacked with inter- 
current affections, passed into the second or hydrocephalic stage of the dis- 
ease. The second stage lasted, according to the same author, in the four 
cases which he witnessed, from eight to thirty months, and then death 
was the result, not of cerebral symptoms, but of complications affecting 
the thoracic organs. 

Diagnosis. — The diagnosis of cerebral hemorrhage is, as I have already 
stated, very difficult, unless hemiplegia exist. When the case com- 
mences, as it often does with convulsions, or with inflammatory symptoms, 
it is often impossible to distinguish it from acute or tubercular disease of 
the brain. 

The diagnosis of meningeal hemorrhage is also very often extremely 
difficult. Not unfrequently it occurs in the course of other diseases, and 
is then entirely latent. In acute, primary cases, the most important and 
distinctive symptoms are the early age of the subjects, between one and 



DIAGNOSIS — PROGNOSIS — TREATMENT. 423 

three years generally ; the violent fever from the commencement, marked 
by full, frequent, and regular pulse ; the absence of constipation ) the fre- 
quency of the convulsive attacks, and particularly the permanent contrac- 
tion with rigidity of the feet and hands. 

The diagnosis between the form of hydrocephalus which follows menin- 
geal apoplexy, and ventricular serous hydrocephalus, is exceedingly ob- 
scure. The only circumstance which seems to have any real value is age. 
MM. Rilliet and Barthez state that they have never known a child of two 
years old, or younger, to die of ventricular serous hydrocephalus from 
tumors whether tubercular or not of the brain ) in all such cases the effu- 
sion has been the result of a sanguine exhalation. 

Prognosis. — The prognosis of both forms of the disease is very grave. 
It is impossible, however, to ascertain the prognosis with any certainty, 
so long as the symptomatology of the two affections is so obscure as we 
have found it to be. That cerebral hemorrhage is susceptible of cure, 
however, is proved by the case reported by M. Valleix, already referred to, 
in which the child had nearly recovered, when it was seized with another 
disease which destroyed it. I have not been able to find any well-authen- 
ticated case of recovery from the meningeal form, though I cannot 
imagine why it may not be susceptible of cure, like any other sanguine 
effusion. 

Treatment. — The treatment must depend on the diagnosis of the case. 
In a sudden and severe attack, occurring in a strong and hearty child, and 
in which the symptoms of sudden pressure on the brain are clearly marked 
or even highly probable, it should be the same as that employed in the 
apoplexy of the adult, that is to say, antiphlogistic. The child ought to 
be bled from the arm, ankle, or external jugular, as soon as possible after 
the invasion, and this can be done generally in private practice within an 
hour. I believe that general bleeding is a much more powerful remedy 
in itself than local depletion, and moreover, it has the immense advantage 
of being applicable instantly upon the arrival of the physician, who can 
perform, or ought to be able to perform, the operation of venesection him- 
self, instead of sending to a greater or less distance for a bleeder, leecher, 
or cupper, to do what the interest of the patient requires to be done 
at once. When, however, it is impossible from any cause to employ vene- 
section, we may substitute leeching or cupping. It is impossible to lay 
down positive rules as to the amount of blood to be taken, as this must 
depend on the age and strength of the child, and the impression made 
upon the symptoms by the detraction. In the case of the girl two years 
and a half old, already referred to, who was attacked suddenly while in 
good health with general convulsions and entire insensibility, I took three 
ounces from the ankles, and applied leeches twice, within twelve hours 



424 CEREBRAL HEMORRHAGE. 

from the onset, taking about nine ounces of blood in all. At the end of 
twelve hours, and after the second leeching, she regained her conscious- 
ness perfectly, but was hemiplegic on the left side. She recovered. 

As soon as bloodletting has been practised, or, if leeches are employed, 
while they are being used, cold applications should be made to the head, 
either by cloths, the ice bladder, or by pouring water from a height from 
a pitcher or kettle. At the same time, or as early as possible after the 
invasion, a dose of some purgative medicine must be given. The best 
is probably calomel, either alone or combined with jalap or rhubarb. If 
given alone, it ought to be followed in an hour or two by castor oil, infu- 
sion of senna and manna, salts, magnesia, or some active cathartic. When 
the symptoms are very urgent, it is well to open the bowels still more 
speedily by a purgative enema. 

Counter-irritants are always useful adjuvants to the remedies already 
mentioned. They should consist at first of mustard plasters applied to 
the extremities, and shifted from place to place. When the symptoms do 
not yield after proper depletion and the use of sinapisms for some hours, 
it is well to apply blisters to the calves of the legs, and to the nape of 
the neck. 

The diet must be very strict, and should consist only of barley or 
arrow-root water, for a few days. 

It ought to be remarked, however, that bleeding is not always proper 
in cases supposed to depend either upon cerebral or meningeal apoplexy, 
for, as has already been stated, the effusion of blood occurs more fre- 
quently perhaps in feeble and weakly children, as a consequence of 
previous diseases which have exhausted the forces of the constitution 
and occasioned a state of diifluence and dyscrasia of the blood, than in 
those of robust and plethoric health. In the former class of cases, deple- 
tion would of course be altogether inadmissible. Such was the character 
of two cases of meningeal apoplexy in children of five weeks and three 
years old, reported (Loc. cit.) by Dr. West. Again, of eight cases of 
cerebral apoplexy observed by MM. Rilliet and Barthez, four coincided 
with more or less general tubercular disease. In such cases as these, we 
must depend upon local depletion to a very moderate extent, if at all, 
and upon the use of purgatives, cold applications, and counter-irritants. 

For the paralysis which follows apoplexy in children, I believe that 
the most important, and indeed the only treatment necessary, is attention 
to the general health of the patient, in order to give to nature time and 
opportunity to effect the absorption of the clot, which has been thrown 
out into the substance of the brain, or of the exhalation which has taken 
place into the cavity of the arachnoid membrane. When the disease 
assumes the chronic form, occasioning the kind of hydrocephalus we have 






ECLAMPSIA. 425 

described, there is little more to be done than to attend to the general 
health of the child, and to promote absorption of the fluid by the internal 
administration of diuretics, and the preparations of iodine. It has been 
proposed also to get rid of the fluid by tapping, as has been done in con- 
genital hydrocephalus, and in some cases of acquired chronic hydroce- 
phalus. 



CHAPTER II. 

NEUROSES, OR DISEASES OF THE NERVOUS SYSTEM, UNATTENDED 
WITH APPRECIABLE ANATOMICAL ALTERATIONS. 

ARTICLE I. 

GENERAL CONVULSIONS, OR ECLAMPSIA. 

G-eneral Remarks. — The word convulsions is a generic term applied 
to different forms of spasmodic disease, very dissimilar from each other 
in many of their characters. 

Writers make different classifications of convulsions according to their 
peculiar notions in regard to the nature and causes of these disorders. 
The best division is, it seems to me, that adopted by most French writers > 
who arrange them by their supposed causes, making three classes, idio- 
pathic or essential, sympathetic, and symptomatic convulsions. The first 
two classes are unaccompanied by appreciable lesions of the nervous 
centres, while the third is called symptomatic, because it includes cases 
of convulsions which are the sign or symptom of an appreciable lesion of 
the cerebro-spinal axis, as for instance, those which occur in the course 
of meningitis, tubercular disease, hydrocephalus, apoplexy, etc. In idio- 
pathic or essential convulsions, the cause of the attack acts directly upon 
the nervous centres, while in those to which the term sympathetic is 
applied, the cause lies in the influence or effect upon the brain or spinal 
marrow, of disease of some other organ ; to the latter class belong the 
convulsions which occur in the course of pneumonia, bronchitis, the erup- 
tive fevers, etc. 

I shall not pretend to give an accurate account of symptomatic convul- 
sions in this article, as they have already been treated of under the head 
of the different organic diseases of the brain in the course of which they 
occur. I shall refer to them in the present article only so far as may be 



426 ECLAMPSIA. 






necessary to elucidate the pathology, diagnosis, prognosis, and treatment, 
of idiopathic and sympathetic convulsions. 

There is a form of eclampsia occurring in children, which I shall de- 
scribe separately, as it differs in many of its characters from ordinary 
convulsions. This is the disease known by the names of spasm of the 
glottis, thymic or Kopp's asthma, laryngismus stridulus, and eclampsia 
with suffocation. 

Definition; Synonymes; Frequency. — By convulsions is meant a 
condition of disease in which the muscular or locomotive innervation is 
deranged and perverted, so that the movements become irregular and 
automatic, and are no longer controlled by the will. 

The only synonymes which it is necessary to mention are epilepsia pue- 
rilis, insultus epilepticus, and eclampsia. The latter term, eclampsia, is, 
I believe, preferable to any other, and I would gladly introduce it instead 
of convulsions, which is too general a term to express the form of disease 
under consideration. 

The frequency of eclampsia is very great. During the five years from 
1844 to 1848 inclusive, 1729 children under fifteen years of age, died in 
this city of convulsions; whilst, during the same time, 1611 died of 
infantile cholera, 1060 of marasmus, 1041 of dropsy of the brain, and 
772 of pneumonia, showing that eclampsia was the cause of a larger 
number of deaths than any other of the diseases just mentioned. It 
must be recollected, however, that a large number of these cases ought, 
in all probability, to have been returned under other titles, as many of 
them, no doubt, depended upon organic disease of the cerebro-spinal axis, 
and other acute local or general diseases. 

Predisposing Causes. — Essential and sympathetic convulsions are 
much the most frequent before the age of seven years, which is the case 
also in regard to symptomatic convulsions, though the latter often occur 
after the age mentioned. Of 86 cases of convulsions that I have met 
with, in which the age was noted, 18 occurred in the first year, 24 in the 
second, 20 in the third and fourth, 21 between the fourth and ninth, and 
3 between the ninth and thirteenth years of life. Dr. West (Lond. Med. 
Gaz. y vol. iv. 1847, p. 884) states that according to the fifth report of 
the registrar-general, the deaths from diseases of the nervous system in 
the metropolis, under one year of age, bcre a proportion of 33 per cent. 
to the deaths from all causes ; from the first to the third year, the pro- 
portion was 20-9 per cent. ; from the third to the fifth year, it was 20 per 
cent.; whilst from the tenth to the fifteenth year, it was only 9-3 per 
cent. Again, to show the very great influence of age upon the predispo- 
sition to convulsions, Dr. West states, that within the first year, the 
deaths from convulsions constituted 74-2 per cent, of the total mortality 



causes. 427 

from diseases of the nervous system j between the first and third years, 
the proportional mortality from convulsions to the total mortality from 
affections of the nervous system, was 27 1 per cent.; between the third 
and fifth, it was 18-1 percent.; while between the tenth and fifteenth 
years, it had fallen to 2-7 per cent. 

Dr. West ascribes the great frequency of convulsions in early life to 
the predominance of the spinal over the cerebral system, and to the im- 
perfect development of the brain. 

It is generally stated that convulsions are more common in girls than 
boys. MM. Rilliet and Barthez, on the contrary, observed them most 
frequently in boys, and such has been my own experience, since of 87 
cases that I have seen in which the sex was recorded, 46 occurred in boys, 
and 41 in girls. • 

It has been generally supposed that a delicate and nervous constitution, 
is a powerful predisposing cause to convulsive attacks. This has been 
denied, however, by several recent writers, whose observations are very 
careful and accurate. I am disposed to believe that it is not so much a 
feeble or delicate constitution that predisposes to convulsions, as it is one 
characterized by a highly susceptible, irritable, and nervous temperament, 
which often exists, in my opinion, in connexion with an apparently healthy 
and vigorous physical organization. Of 91 children in whom I have seen 
convulsive attacks, these occurred more than once in 12. Of the 12, nine 
presented every appearance of strong and vigorous health, with the ex- 
ception that when laboring under any kind of sickness, as dentition, indi- 
gestion, the fever accompanying simple angina, in two the invasion of 
measles, and in one that of erysipelas, they immediately became extremely 
restless and irritable, or heavy and drowsy, and at a very early period, 
and sometimes with very little warning, were seized with convulsions. 
Three of the 12 were delicate : one was puny and feeble until after the com- 
pletion of the first dentition, when it grew strong and hearty ; one had had 
an apoplectic attack when an infant, which had caused partial loss of power 
of one side ; and the third was very weak at birth, then grew stronger, and 
died in its second year of hydrocephalus following scarlet fever. The num- 
ber of convulsions varied in the different subjects. In 1 there were five 
different attacks, in another four, in 4 there were three, and in 5, two. 
In one the attacks were very numerous, recurring frequently, and from 
very slight causes. They all recovered but one, and are still living. Of 
the 11 now living at various ages, all but one are free from anything like 
epilepsy, and that one, though still liable to attacks of an epileptiform 
character, is becoming gradually less and less subject to the seizures. 

It is generally believed that the predisposition to convulsions is some- 
times hereditary. I have remarked in regard to this point, that several 



428 ECLAMPSIA. 






children in the same family sometimes suffer from the disease, and that 
the nervous temperament to which I alluded above, appeared in some 
instances to have been inherited by the child from its parents. 

The exciting causes of convulsions are exceedingly numerous and dis- 
similar. Amongst the causes of essential convulsions are cited vivid 
moral emotions, violent pain, high temperature, exposure, with the head 
uncovered, to the sun, and sudden exposure to cold. In many cases, how- 
ever, the exciting cause cannot be detected. The exciting causes of sym- 
pathetic convulsions may be almost any of the diseases incident to child- 
hood. Amongst them I will cite as probably the most frequent, hooping- 
cough, pneumonia, scarlatina, measles, violent fever from any cause, 
dentition, and indigestion. 

Of 91 cases of convulsions that have come under my notice, I have 
regarded only 3 as essential, whilst 66 were sympathetic, and 22 sympto- 
matic. Of the 3 essential cases, I could not detect the exciting cause in 
any. Of the 66 sympathetic cases, it was scarlet fever in 8 ; pertussis in 
9 ; indigestion in 13 ; pneumonia in 3 ; the fever of simple angina in 6 ; 
cholera infantum and bronchitis, each 3 ; dysentery, 4 ; measles and den- 
tition, each 6 ; enteritis, the fever and irritation caused by a burn upon 
the back, and the onset of erysipelas, each 1 ', an over-dose of castor oil 
(Jvi) given to a young child with a slight cholera, 1 ; and lastly, foecal 
accumulations in the large intestine, 1. 

Symptoms. — Prodromic Symptoms. — It has been asserted by some 
writers that most attacks of convulsions in children are preceded by pro- 
dromic symptoms, which indicate to the experienced eye their approach- 
This does not agree exactly with my own experience, at least in regard to 
the essential and sympathetic forms, since of the cases of the former 
variety, well-marked prodromes did not occur in any, and of 64 cases of 
the latter, in which the early symptoms were noted, strongly-marked pre- 
cursory phenomena occurred only in 8. I do not mean to say that there 
were no symptoms in the other 56 cases, which might have indicated to 
an experienced eye the probability of an approaching attack of convulsions, 
but merely that there were none that were strikingly characteristic, none 
which pointed out clearly and decisively that such a crisis was close at 
hand. In many of the 56, there were symptoms that might be regarded 
as indicating, with various degrees of probability, the approach of the 
convulsive seizure ; but, inasmuch as they were such as constantly exist 
in children not predisposed by temperament or constitution to eclampsia, 
without the development of the disease, they scarcely deserve to be called 
precursory symptoms. 

The precursory symptoms of idiopathic and sympathetic convulsions are, 
therefore, difficult to describe because of their variable and uncertain 



SYMPTOMS. 429 

nature. They consist in general, however, of whatever indicates a highly 
disordered condition of the nervous system. The most marked symptoms 
are unusual drowsiness, excessive irritability, a peculiar physiognomical 
expression, general tremors, and the drawing of the thumbs into the palms 
of the hands, or rigid flexion of the toes. The drowsiness which precedes 
an attack of eclampsia, is almost always accompanied with some restless- 
ness. The sleep is light and easily disturbed ; the child moves and turns, 
or starts and moans ; often it seems to have frightful dreams, and will 
scream out or wake suddenly, bewildered and terrified, and when roused 
is generally exceedingly irritable, crying violently or fretting at the 
slightest contrariety, or without cause. The face, and particularly the 
eyes, often exhibit a peculiar expression altogether different from their 
usual appearance. The expression which has most struck me, and which 
I have seen on several occasions, is a fixed and staring look, lasting but 
for an instant, as though the child were looking intently at some object, 
while in fact it is gazing at vacancy ; at the same time the expression is 
entirely without meaning. The child seems in fact, for a moment, to be 
in a state of extasis. In some instances a sardonic smile is seen to pass 
over the countenance just before the attack. The tremors or tremblings 
alluded to above, occur both in the sleeping and waking state, but parti- 
cularly in the former. Flexion of the thumbs and toes has been noticed 
by different observers, but is, I believe, a sign rather of the approach of 
symptomatic, than of essential or sympathetic convulsions. 

The precursory symptoms of symptomatic convulsions will depend on 
the nature of the disease in the course of which they occur. Not unfre- 
quently the convulsions occur at the very outset of the disease of the 
brain or spinal marrow, when of course there will be no prodromic symp- 
toms whatever. According to Dr. Marshall Hall (Diseases of the Nervous 
System, p. 149), the first and most frequent sign showing that the excito- 
motory system is becoming complicated in diseases of the brain is vomit- 
ing, after which come strabismus, a contracted state of the muscles of the 
thumbs or fingers, or some unequivocal spasmodic or convulsive affection 
of the respiratory muscles, or of the muscles of the limbs. 

Symptoms of the Attack. — With or without the precursory symptoms 
just described, the convulsive movements generally begin in the eyes, 
which, for a moment are fixed and staring, and then drawn obliquely up- 
wards under the upper lid, so that the white portions of the balls alone 
are visible for an instant between the partially open lids. During the 
attack the eyes are rarely fixed in one position, but are constantly agitated 
in various directions, from side to side, or upwards and downwards ; very 
often there is the most violent strabismus; the eyelids are sometimes 
open, at others shut; the pupils may be contracted or dilated. The 



430 ECLAMPSIA. 

muscles of the face next enter into contraction, and occasion the most 
hideous contortions of the features. The mouth is distorted into various 
shapes, the lips are often covered with a whitish or sanguinolent froth, and 
the jaws tightly clinched together by tonic spasms, or agitated by con- 
vulsive movements, so as to produce grinding of the teeth. The trunk of 
the body generally becomes rigid and stiff from tonic contractions of its 
muscles, though it also is sometimes variously contorted by clonic convul- 
sions. The head is usually strongly retracted upon the trunk, but in 
other instances is drawn to one side, or violently rotated. The muscles 
about the front of the neck enter into action, and alternately elevate and 
depress the larynx ; the tongue, when it can be seen, is observed to be 
moved in different directions, and is sometimes caught between the teeth 
and severely bitten. The extremities, particularly the superior, are more 
violently convulsed than any other parts. The fingers are drawn into the 
palms of the hands, the forearms are flexed and extended upon the arms by 
short, rapid and generally rhythmic movements, the hand is quickly pro- 
nated and supinated upon the arm, or finally the whole upper extremity 
is twisted and distorted into various positions, which it is impossible to 
describe. The inferior extremities undergo similar movements, but almost 
always in a less degree than the upper. The respiration during the attack 
is irregular, sometimes suspended by rigid spasm of the respiratory 
muscles, and sometimes accelerated. A spasmodic contraction of the 
larynx, producing noisy inspirations, has been noticed by several writers. 
We shall find when we come to consider the nature of this disease, that 
Dr. Hall is of opinion that a more or less complete closure of the larynx is 
the most important feature of the convulsive crisis. The face is often 
livid and deeply congested, especially when the respiration is embarrassed ; 
the head is hot, whilst the extremities are cold; the pulse becomes large 
and full, or frequent and small, and sometimes cannot be counted in con- 
sequence of contraction of the muscles of the forearm. The face is not 
always however congested. I have sometimes seen it perfectly white, 
while the convulsions were severe, and the child profoundly insensible. 
The action of the heart is tumultuous, and sometimes irregular or inter- 
mittent. When the attack is very violent, the urine and faeces are occa- 
sionally discharged involuntarily, but these are rare symptoms. Deglu- 
tition is seldom impossible even in the severest fit. In severe, and espe- 
cially long-continued attacks, intellectual consciousness, and general and 
special sensibility are all abolished. In milder cases, though conscious- 
ness is destroyed, some of the special senses still respond to irritants, 
whilst in still slighter cases, the intelligence also is more or less pre- 
served. 

Convulsions are not always as we have just described them, general. 



SYMPTOMS. 431 

They may be circumscribed or partial, affecting one side of the body more 
than the other, or one side alone, or a single arm. Sometimes they 
attack the eyes only. The inferior extremities are rarely affected alone. 
Of the partial convulsions the most frequent are those in which some parts 
of the face and upper extremities are attacked. In this form of the disease, 
the disorders of the circulation and respiration, the congested tint of the 
face, the froth upon the lips, and the derangements of intelligence and 
sensibility, are much less strongly marked than in general attacks. 

The duration of an attack of eclampsia concerns both the length of the 
convulsive crisis, and the continuance of the disposition to renewals of the 
crisis. Both of these are very uncertain. I have known the attack to 
last in all its violence eight hours and a half in one case, and twelve in 
another, and it is said to have lasted much longer in some instances. 
When the spasmodic movements continue during a long period, they are 
almost always interrupted by remissions. As a general rule, the dura- 
tion is much shorter than the periods above mentioned, — from a few 
minutes to half an hour. "When the attacks cease and recur as they often 
do several times a day, they leave the patient during the interval in a 
state of more or less perfect consciousness or somnolence, restlessness or 
delirium, or finally of coma. The period during which the disposition to 
recurrence continues, depends ^principally upon the cause of the convul- 
sions. If this continue in action, they will be apt to return until it is 
removed. 

Idiopathic and sympathetic convulsions generally consist of a single at- 
tack, though there are sometimes several, which occur at intervals of some 
hours, or of one or two days. Sympathetic convulsions usually occur 
either at the beginning or termination of the disease which they compli- 
cate, and much less frequently during its middle period. Of 42 cases of 
this form observed by myself, complicating measles, scarlet fever, erysi- 
pelas, pneumonia, bronchitis, cholera infantum, simple angina and dysen- 
tery, in which the period was carefully ascertained, they occurred at the 
invasion alone in 21, at the termination alone in 15, at the middle period 
alone in 3, and at the invasion and termination both in 3. It is curious 
to remark, that of the 21 cases that occurred only at the invasion of the 
disease, all but 3 recovered ; that the 3 occurring in the middle period 
alone also recovered ; that of the 3 occurring both at the invasion and ter- 
mination, 2 died ; and that all of those which occurred at the termination 
alone, proved fatal. 

MM. Killiet and Barthez state that half the cases of symptomatic con- 
vulsions observed by them, occurred at the commencement of the ence- 
phalic disease. This form seldom consists of a single crisis ; the attacks 
on the contrary, are repeated from time to time. The authors just quoted 



432 ECLAMPSIA. 

state that whenever the convulsive attacks have recurred repeatedly within 
an interval of a few days, they have proved symptomatic of disease of 
the brain. 

Nature of the Disease. — It seems to me that the only plausible 
and satisfactory explanation of the pathology of convulsions in children, 
is that afforded us by the physiological doctrines in regard to the nervous 
system set forth by Dr. Marshall Hall in his writings. Dr. Hall says 
(Diseases and Derangements of the Nervous System, p. 145), " That the 
whole class of convulsive diseases consists of affections of the true spinal 
system, there is no longer any doubt. But these diseases do not all origi- 
nate in this system." All convulsive disorders are, according to this doc- 
trine, affections of the true spinal or excito-motory system. The causes 
of these disorders may be of incident origin, acting upon excitor nerves ; 
of centric origin, seated in the brain or spinal marrow ; or of reflex origin, 
acting upon reflex or motor nerves. They are called, therefore, according 
to their causes, central or centric, when they depend on disease of 
the nervous centres ; centripetal when they are excited through excitor 
nerves ; and centrifugal when they depend on disease of the motor nerves. 
Dr. Hall ascribes great importance to the condition of the glottis in con- 
vulsions. He says (p. 323), in speaking of epilepsy, " The second symp- 
tom is a forcible closure of the larynx, and expiratory efforts, which suf- 
fuse the countenance, and probably congest the brain with venous blood." 
At page 327, he says, " A spasmodic affection of the larynx has obviously 
much to do in this disease (epilepsy), as well as in the crowing inspiration 
or croup-like convulsion of infants; so much, indeed, that I doubt whether 
convulsion would occur without closure of this organ." In describing the 
croup-like convulsion or laryngismus stridulus (p, 180), he says : " I must 
repeat the observation that the respiration is actually arrested by the clo- 
sure of the larynx ; and there are forcible expiratory efforts only, or prin- 
cipally, in the actual convulsion." 

In a recent publication Dr. Hall says : " without closure of the larynx, 
extreme laryngismus, and the consequent congestion of the nervous cen- 
tres, there could, I believe, be no convulsion ! This closure of the larynx 
must be complete, in the affection under consideration ( laryngismus stri- 
dulus), as in all others, before convulsions can take place." (Braiih. Ret. 
from Lancet, June 12, 1847, p. 609.) 

It is easy to comprehend the mode of production of sympathetic con- 
vulsions by reference to these doctrines. They evidently depend upon 
morbid impressions conveyed to the true spinal system through the exci- 
tor nerves, which have their origin in the diseased organs. Thus it is 
easy to understand why inflammation of the parenchyma of the lung in 
pneumonia, of the bronchial mucous membrane in bronchitis, of the mu- 






causes. 433 

cous membrane of the bowel in entero-colitis or dysentery, or of the pha- 
rynx in angina ; why the pressure of a tooth upon an inflamed gum during 
dentition, the presence of a foreign body, as newspaper, or crude food, in 
the stomach, or fecal accumulations in the intestines, should produce a 
degree of irritation in excitor nerves, sufficient, when transmitted to the 
spinal centre, to occasion the convulsions we have been considering. 

It is more difficult to explain the mode in which continued fevers, mea- 
sles, scarlatina, &c, give rise to convulsions. To me, however, their oc- 
currence seems readily explained by the morbid effect produced upon the 
nervous centres by the blood, which is known to be more or less changed, 
in these affections, from its healthful condition, and also by the mere fact 
of the existence of fever ; for I have met with a number of children in 
my practice, who are almost certain to have a convulsive seizure, whenever 
the circulation becomes greatly excited in force and frequency by the exist- 
ence of fever, no matter what be the cause of that fever. 

The explanation of the production of idiopathic or essential convulsions 
is not always so easy, because we are sometimes unable to detect any cause, 
either centric, centripetal, or centrifugal, to account for the excitation of 
the spinal system. It seems probable, however, that they must depend, 
like those of the sympathetic form, upon some unhealthful, and therefore 
irritating condition, acting upon the excito-motory system of nerves. The 
cause may be so slight as to escape the notice of the physician, and yet 
sufficient to produce a convulsive crisis in a child predisposed to eclampsia. 
It may be an unnoticed dentition, some undigested food in contact with 
the stomach or intestines, or accumulations of unhealthy fecal substances 
in the intestines. When convulsions have followed a vivid mental emo- 
tion, as passion or vexation, they are evidently a result of the influence 
of that condition upon the nervous centres. Acute pain, which is said 
to have occasioned essential eclampsia, as well as exposure to violent heat 
or severe cold, must produce their effects through their action upon inci- 
dent excitor nerves. 

All symptomatic convulsions belong, of course, to the class of centric 
diseases. These need no further remarks. 

Diagnosis. — There are two important points to be considered in treat- 
ing of the diagnosis of eclampsia : the diseases with which it may be 
confounded, and the causes which may have produced the convulsions, 
or, in other words, their distinction into essential, sympathetic, and 
symptomatic. 

The only disease with which eclampsia is likely to be confounded, is epi- 
lepsy ; the mistake could only be made when the former is violent, and when 
it is accompanied and followed by unconsciousness. In epilepsy, however, 
the invasion is more sudden, the convulsions are accompanied with greater 

28 



434 ECLAMPSIA. 

rigidity, there is always frothing at the mouth, the duration of the crisis 
is shorter, and it is generally followed by more marked stupor. If the convul- 
sive attack have occurred under the influence of an appreciable cause, if 
the parents are not epileptic, and if the child is very impressionable, it is 
probably eclampsia. Again, the younger the patient, the more likely is 
the case to be one of eclampsia ; whilst if the child is approaching towards 
puberty, if the attacks are frequently repeated, and yet followed by com- 
plete restorations to health in the interval, the disease is much more likely 
to be epilepsy. 

The diagnosis of the form of the attack, whether idiopathic, sympa- 
thetic, or symptomatic, is exceedingly important, as upon this must de- 
pend in great measure the prognosis and treatment. It is often very dif- 
ficult, and sometimes impossible, to determine at the moment, to which 
class the convulsions belong. The most difficult points in the diagnosis 
are the following : first, when a child previously in good health, is sud- 
denly seized with the disease, to determine whether it is essential ; whether 
it is sympathetic and occasioned by disease which, up to this instant, has 
been latent, or by the invasion of some one of the acute local diseases, 
or of one of the continued fevers ; or lastly, whether it is symptomatic, 
marking the invasion of a disease of the cerebro-spinal axis : second, when 
the convulsion occurs in the course of a disease not implicating the ner- 
vous centres, to determine whether it is merely sympathetic of that dis- 
ease, or whether it is symptomatic of the invasion of an intercurrent 
affection of the brain or spinal marrow. 

It is impossible, for want of space, to treat of all these points in detail. 
The enumeration of them, however, will be useful in calling the attention 
of the reader to their importance. 

An essential convulsion is only to be distinguished by careful study of 
the antecedent history and present condition of the patient. If, after a 
thorough examination of all the organs, no diseased point can be detected 
and if the child recover perfectly from the convulsion, we must conclude 
that the case has been an idiopathic one, in which the cause is beyond our 
reach. I am disposed to believe, however, as has already been stated, 
that in most such cases there has been a source of irritation in some of 
the organs of the body, which has acted as the excitant to the excito- 
motory system, and which, if we could but detect it, would warrant us in 
classing the case amongst sympathetic convulsions. 

The sympathetic and symptomatic forms of eclampsia are to be diagnos- 
ticated by the same careful attention to the antecedent history and present 
condition of the child. If the latter is teething at the time of the fit, and there 
is no other cause to explain the attack, and should there be nothing in the 
consecutive symptoms to render such an explanation inadmissible, we may 



DIAGNOSIS — PROGNOSIS. 435 

refer it to that condition. I may remark merely, that, as a general rule, 
eclampsia depending entirely upon the irritation of dentition, is seldom 
either violent or long-continued, and that the return to consciousness and 
health is speedy. The probable dependence of the attack upon indiges- 
tion is to be ascertained by the absence of other causes, and by our learning 
upon inquiry that the child had eaten of some indigestible substance within 
a few hours or a day before the attack. Its dependence on intestinal ac- 
cumulations is to be arrived at by the same negative or exclusive method, 
and by learning that the patient is usually, or has been of late, of a con- 
stipated habit. 

When the attack occurs in the course of some other disease, as pneu- 
monia, enteritis, pertussis, scarlatina, or measles, it is almost certainly 
sympathetic. It may possibly, however, be indicative of an intercurrent 
attack of cerebral disease. This can be determined only by attention to 
the consecutive phenomena. If the attack be short, and soon followed by 
complete restoration to consciousness, it is in all probability sympathetic. 
If, on the contrary, the convulsive crisis be long and severe, if the reco- 
very from it be slow and imperfect, if it be followed by violent agitation, 
somnolence or coma, or by some persistent lesion of motility, there is every 
reason to fear an attack of disease of the brain. 

Sympathetic convulsions occurring at the invasion of different local or 
general diseases, are to be distinguished only by observation of the symp- 
toms that follow the crisis, which will be those belonging to the particular 
malady whose approach has caused the attack of eclampsia. 

Symptomatic eclampsia is characterized by various signs of encephalic 
disorder, which rapidly succeed the convulsive attack. The most impor- 
tant of these are severe and continued headache ; diminution or exaltation 
of general or special sensibility ; dilatation or contraction of the pupils \ 
irregular movements of the eyes; flexion or stiffness of some of the limbs, 
or of the fingers or thumbs ; disordered intelligence ; or the symptoms 
which have already been described in the articles upon the diseases of the 
brain. 

Prognosis. — The prognosis of essential convulsions must depend on 
the nature of the cause, and the violence of the attack. When the cause has 
been slight, or one which soon ceases to act, or can be readily removed, 
the prognosis is much more favorable than under opposite conditions. If 
the convulsive crisis is short and of moderate severity, if the pulse and 
respiration are but slightly disturbed, if there be but little congestion of 
the face, and no stertor, there is every reason to hope a successful issue in 
the case. Of the three cases of this class that I have seen, two recovered 
and one died. 

Sympathetic is more dangerous than essential eclampsia, but much less 



436 ECLAMPSIA. 

so than symptomatic. The prognosis will depend chiefly on the nature of 
the disease which it complicates, and on the stage of that disease at which 
it occurs. Thus, in scarlatina, convulsions are almost always fatal, in 
measles much less so, and in other diseases in various proportions. 
They are very apt to terminate unfavorably when they occur after the 
malady which they complicate has been in progress for several days. 
This is a remark made by various authors, and I have already stated that 
of 42 cases of this form in which I carefully ascertained the period of 
their occurrence, 21 appeared at the invasion, of which all but 3 ended 
favorably ; 3 at the middle period, which all recovered ; 3 both at the 
invasion and at a later period, 2 of which were fatal ; and 15 after the 
cases had been progressing for a considerable time, all of which proved 
fatal. In addition to these important elements for making the prognosis, 
we must consider, also; the duration and degree of violence of the parox- 
ysm, the state of the patient after the fit as to the cerebro-spinal functions, 
and lastly the age and constitution of the child. 

The prognosis of symptomatic convulsions must depend very much 
upon that of the disease of which they are the symptom. It may be 
stated as a general rule, that, like those of the sympathetic class, they are 
less dangerous when they occur at the beginning than a later period of 
the disease. They are always, however, very dangerous. Of 22 cases 
that I have seen, 19 were fatal. 

Treatment. — I shall confine my remarks upon the treatment of 
eclampsia to the essential and sympathetic forms of the disease, having 
already treated of that of the symptomatic form in the articles upon the 
cerebral diseases which give rise to them. 

It seems to me that the treatment of eclampsia in children may be sim- 
plified if we pay attention to two distinct conditions of disorder, which appear 
to exist in every case. These are the condition of morbid irritation or 
derangement of the excito-motory system of nerves, and the cause which 
occasions that derangement. The condition of irritation or disease of the 
true spinal system exists in all cases, and is always the same, differing 
only in degree and extent ; whilst the morbid cause of that irritation 
differs in each case, being in one dentition, in another pain, in another 
constipation, in others pneumonia or indigestion, pleurisy or angina, 
scarlet fever, measles, fright, or other violent emotions. If this view 
of the subject be correct, it is clear that in treating a case of convulsions, 
we have to attend to the two morbid conditions referred to, and I shall 
be careful, therefore, in the course of my remarks, to treat of the reme- 
dies most proper for the removal of the cause, whatever it may be, which 
acts as the irritant to the spinal system ; and of those proper to subdue 






TREATMENT. 437 

or allay the deranged condition of the spinal system and the effects of 
that derangement. 

There are some general rules to be followed in the treatment of con- 
vulsions which apply to all cases, and of these I shall first speak. They 
are, to place the child in a large, well-ventilated room, if such can be pro- 
cured j if it have been seized in a little close room, where the atmosphere 
is dense and impure, removal to another room, or exposure to fresh air 
before an open window, has sometimes sufficed to terminate the crisis. 
At the same time the clothes of the child should be loosened, in order to 
prevent all constriction, and if necessary, taken off, to allow of a careful 
examination of the whole body. I believe that it is a good rule always 
to place the child, no matter what the cause of the convulsion may be, if 
it be at all a severe one, in a warm hath (96° or 97° F.) This has fre- 
quently proved an efficient remedy, according to my experience. It is 
easily procured in most cases, and I am quite confident that I have never 
known it do harm, though I have used it in almost every case. The 
patient should be kept in the bath some ten, fifteen, or twenty minutes, 
or until the convulsive movements cease ; when taken out it is most con- 
venient, and at the same time useful, to envelope it in a small, light 
blanket, or flannel, for a short time, before the clothes are readjusted. 

If the convulsion occur in a strong and vigorous subject ; if it be violent, 
and accompanied by a deep red, or yet more by a livid flush of the face, 
and distension of the veins of the head and neck ; if it last more than a 
few minutes, or is repeated after short intervals of quiet, I would in all 
cases, without hesitation, recommend the use of bloodletting. The detrac- 
tion of blood is called for, in my opinion, for the same reasons as in 
puerperal convulsions, and indeed in every violent convulsive attack, — to 
save the nervous centres from the effects of the paroxysm, which are in 
all severe cases, excessive congestion, and in some, fatal effusions. It is 
useful, moreover, by means of the sedative and relaxing influence which 
it exerts upon the whole economy, and particularly upon the sanguine 
and nervous apparatuses. I think, therefore, that we may lay it down as a 
rule, to employ bloodletting in all instances, except those in which the 
convulsion depends upon an anaemic condition, and in which it is contra- 
indicated by a naturally feeble or by a debilitated state of the constitution ; 
those in which it is clearly unnecessary from the slight severity or short 
duration of the attack ; or those which occur in the course of other dis- 
eases, and particularly at their termination, and in which a resort to it is 
rendered evidently improper by the circumstances of the concomitant 
affection. The quantity of blood to be taken, and the method, must 
depend on the circumstances of the case. It is best to bleed generally 
whenever this is possible, as the operation is much more speedily per- 



438 ECLAMPSIA. 

formed than local bleeding, and because the sedative and relaxing effects 
of the detraction upon the economy are more powerful. The blood may 
be taken either from the arm or jugular vein. We must be guided as to 
the quantity by the age and constitution of the patient, the violence and 
duration of the paroxysm, and the cause of the attack. In a strong, 
hearty child, two or three years of age, in whom the attack is violent, 
and produced by some cause not likely to continue long in action, and 
thereby exhaust the strength, we may take from four to six ounces at the 
first bleeding, and should this fail to exert an influence upon the paroxysm, 
a rather smaller quantity may be taken in one or two hours afterwards. 
In younger children, or those who are somewhat feeble or delicate, the 
amount drawn ought to be less. When general bleeding cannot, from 
any cause, be employed, we may resort to cups and leeches to the temples 
or back of the neck, or, as advised by some of the French writers, to 
more distant parts. 

I believe it is useful in all cases of essential and sympathetic convul- 
sions, which resist the employment of a warm bath and bleeding, and also 
when bleeding cannot be or is not resorted to, to make use of an emetic of 
some kind. The act of vomiting alone is often sufficient to break up a parox- 
ysm of convulsions which has resisted various other means. This I learned 
first from the advice of an old and experienced practitioner, who was in 
the habit of employing emetics in all cases of eclampsia of children, and I 
have since seen it tested on numerous occasions. Dr. Hall recommends the 
induction of vomiting in the treatment of the paroxysm of the croup-like 
convulsion or laryngismus stridulus, and as a means of prevention in epi- 
lepsy. In the former he employs irritation of the fauces by tickling with 
a feather; in the latter, ipecacuanha. He says that a new mode of action 
is induced in the true spinal system by the act of vomiting, so that the 
disposition to closure of the larynx, and expiratory efforts, is exchanged 
for sudden acts of inspiration. The emetic which I employ is ipecacu- 
anha. It may be advantageously combined with tartar emetic in the case 
of a vigorous child, especially if no depletion have been used. The 
employment of emetics is, of course, particularly called for, whenever 
there is a suspicion of the presence of undigested food or of foreign bodies 
in the stomach. 

In addition to warm baths, bleeding, and emetics, cold applications to 
the head will be found proper and useful in nearly all cases which are of 
any considerable violence. Their use would be improper, however, when 
the surface is pale, the features contracted, and the pulse small and feeble • 
but, whenever the skin, especially that of the head, is deeply colored and 
turgid, and the pulse full and strong, they ought to be employed from the 
beginning. While the child is in the bath, its head may be wrapped in a 



TREATMENT. 439 

cloth wet with ice-water; or after it has been removed, cold water may be 
poured from pitchers or a tea-kettle upon the same part. If the latter is 
done, enough should be employed to prevent the sudden reaction which 
inevitably takes place when but a small quantity is used. During the 
after treatment of the case, the cold applications ought to be continued so 
long as the head remains unnaturally heated. 

The administration of a purgative dose is proper and useful in many 
cases of convulsions; particularly when it is found upon inquiry that the 
child has been constipated prior to the attack ; when it is suspected that 
the bowels may contain crude food or some foreign body ; when it is 
desirable to produce an evacuant effect in a strong plethoric child, or a 
derivative action from the brain, and when the attack is attended with 
violent determination of blood towards that organ. The best purgative in 
severe cases occurring in hearty children is calomel. It is advantageous 
because of its easy administration, its speedy operation, and the powerful 
sedative influence which it exerts upon the whole economy. The dose 
should be from three to six grains, according to the age. It ought to be 
followed in one or two hours by some other cathartic, which may be either 
castor oil, rhubarb, jalap, or salts. The best of all is castor oil if it can 
be given. When the attack is slight or the patient weak and delicate, 
castor oil is particularly applicable, as it operates with so little irritation 
to the intestine. Whatever the remedy may be, it should be given only 
in such quantity as to produce complete evacuation of the bowels and a 
moderate derivation upon those organs, without the risk of occasioning a 
degree of irritation sufficient to increase the disturbance of the nervous 
system already existing. 

In many cases of eclampsia it will be found that purgative cnemata 
are of great service. They may be administered immediately before or 
after the bath, and not unfrequently have the effect of stopping the 
paroxysm. They may consist of water holding in suspension or solution 
castile soap, common salt, molasses, castor oil, sweet oil, or spirits of 
turpentine. If the first fails to operate in ten or fifteen minutes, another 
or even a third ought to be given. 

Revulsives are of the utmost importance in the treatment of convulsions. 
They should be employed from the very first, or immediately after the 
use of the bath. In slight attacks, they alone are often sufficient to sus- 
pend the paroxysm, or at least the fit often ceases under their use. 
Mustard is the most useful and convenient form of application in the 
great majority of cases. It may be used either in the form of sinapisms, 
which are to be shifted from place to place, or in that of the foot-bath. 
When sinapisms are used, they should always be covered with gauze or 
fine muslin, to avoid the danger of leaving any of the mustard upon the 



440 ECLAMPSIA. 

skin after they are taken off. I once saw very bad ulcerations upon the 
feet of a child from the neglect of this precaution. In the hurry and 
bustle of the moment, the feet were not washed when the plasters were 
removed, and the mustard that remained produced vesications which 
ulcerated. In obstinate attacks, the revulsives ought to be reapplied from 
time to time, taking care to shift their position in order to avoid vesi- 
cation. 

Antispasmodics are highly recommended by some writers upon the 
disease, and particularly by M. Brachet, who appears to have used with 
great effect the oxide of zinc in combination with extract of hyoscyamus. 
I have had but little experience in regard to their use, but confess myself 
indisposed to resort to them except after the employment of the means 
already detailed ; during the intervals between the fits, when these occur 
from time to time ; and as a means of prevention in children threatened 
with the disease. There can be no doubt, from the evidence adduced in 
regard to their effects, and from what I have myself seen of the influence 
exerted by valerian upon the convulsive phenomena of acute cerebral 
diseases, that they have a considerable power of allaying the disorder of 
the locomotive apparatus present in all convulsive affections. As a means 
of prevention, therefore, as adjuvants to other remedies, and in children 
of very nervous, irritable temperament, and delicate constitution, in whom 
it is improper to use the more powerful agents already detailed, I would 
advise a recourse to substances of this kind. The ones most highly re- 
commended are valerian, oxide of zinc, assafcetida, and camphor. Of 
these, valerian is the one I have usually employed. It is best given 
in the form of the fluid extract, of which from ten to twenty drops may be 
administered in water, to a child two years old, every half hour or hour, 
until several doses have been exhibited, after which it ought to be sus- 
pended for a while or given in smaller quantity. M. Brachet gave the 
oxide of zinc in combination with extract of hyoscyamus, to the amount 
of at least two grains of the former and four of the latter in twenty-four 
hours, divided into four, eight, or twelve doses. A dose was given every 
two or three hours, and when the symptoms were very violent, the "first 
two or three were repeated at much shorter intervals. M. B. says, 
speaking of this remedy (Traite Prat, des Convulsions dans V Enfance. 
Deux. edit. p. 402-3), "I always found it to produce quiet; but whilst 
the cause remained, the quiet was only momentary, and the remedy seemed 
to have produced no effect." . . . . " This remedy does not destroy 
the cause (of the convulsion), but it allows time to treat it by calming the 
nervous erethism." 

Opium is a remedy which requires much care and discrimination in its 
employment, but which in certain conditions of the disease, is of the 



TREATMENT. 441 

greatest service. It should rarely be given while there remains any evi- 
dences of considerable determination of blood to the brain, but when this 
condition does not exist, or after it has been removed by bloodletting and 
the use of revulsives, opium often proves very useful in allaying irrita- 
bility and restlessness, which themselves seem to keep up a disposition to 
a return or continuance of the convulsive phenomena. Somnolence also, 
and still more, coma, likewise contraindicate the use of opium. Dr. 
Eberle thinks he has seen much advantage from frictions over the spinal 
region, with a mixture of equal parts of oil of amber, laudanum, and spirits 
of camphor, particularly in very young infants. 

I shall here conclude my remarks upon the general treatment of 
eclampsia, and proceed to make some observations on the conduct to be 
pursued under particular circumstances. 

It is always highly important for the direction of the treatment, to dis- 
cover the cause of the attack. This is sometimes very easy, while in 
other instances it is exceedingly difficult, and not unfrequently, impossi- 
ble. If the attack occur in the course of some acute disease, as pneu- 
monia, angina, enteritis, or dysentery, or during the progress of one of 
the eruptive diseases, the diagnosis of the case is, as a general rule, very 
easy. If, on the contrary, it occurs at the commencement of one of these 
affections, the diagnosis will be much more difficult, unless indeed the 
symptoms of the concomitant disease have already declared themselves, 
or should do so very soon after the convulsion. The treatment in such cases 
should be that laid down in our general remarks, modified, however, by 
the requirements of the particular disease during the course of which the 
eclampsia occurs. 

When the attack occurs suddenly in a child previously in good health, 
or who had been merely slightly ailing for a few hours, the detection of 
the cause is still more difficult. The most probable causes, under such 
circumstances are, however, dentition, indigestion, intestinal disorder, or 
the approach of an acute general or local disease. It is easy to determine 
by inquiry of the attendants, and by examination of the mouth, whether 
the child is teething or not. As a general rule, the convulsions which 
depend solely on the process of dentition, are slight, and last but a short 
time. In all the instances that I have seen, in which such was the only 
cause to be detected, the attack was of this nature. The treatment in 
such instances is to lance the gums, if they are swelled and inflamed over 
the advancing teeth : to use warm baths, and to administer enemata. 
These simple means will seldom fail when eclampsia depends on the 
process of dentition alone. But when, on the contrary, there is present 
indigestion, intestinal accumulations, or enteritis, as often happens during 
dentition, the case becomes more serious, and requires, in addition to the 



442 ECLAMPSIA. 

treatment above described, one directed to the particular coexisting morbid 
condition. 

The existence of indigestion as the cause of the attack, can be discovered 
only by ascertaining with great care the diet of the child during the pre- 
vious days. If it appear that something of an indigestible nature has 
been eaten within a short time, and if, at the same time, it be impossible 
to detect any more evident or probable cause for the attack, we should 
have a right to conclude that it depends upon indigestion. Under these 
circumstances the proper treatment is the immediate use of the warm 
bath, and the earliest possible administration of an emetic of ipecacuanha. 
The operation of the emetic may often be hastened by tickling the fauces 
with a quill. If the paroxysm be very severe and long-continued, bleed- 
ing ought to be resorted to. 

The presence of intestinal accumulations as the cause of the paroxysms 
may be inferred, when it is found upon inquiry that the patient has been 
constipated for some days, or that the stools have been scanty and hard, 
or scanty and very offensive ; when the abdomen is distended and hard, 
and the distension is ascertained by palpation and percussion, not to be 
merely tympany ; and, lastly, when there is no more evident cause for 
the attack. In such a case the particular treatment is the use of purga- 
tives and enemata, in addition to the other means detailed. 

The dependency of the attack on the approach or commencement of 
some acute general or local disease, can be inferred only from a very 
careful examination of the antecedent and present phenomena of the case. 
One of these may be suspected as the cause when we can account for the 
occurrence of the convulsion on no more reasonable supposition ; when 
neither dentition, indigestion, nor intestinal irritation exist. It is scarcely 
likely that a convulsion could be occasioned by any of the acute thoracic 
or abdominal affections, unless the disease had already gone far enough to 
allow a careful examination of the different rational and physical symp- 
toms, to determine its existence. Perhaps the most difficult cases to 
diagnosticate, are those which occur at the beginning of the eruptive 
fevers. Even here, however, a careful search for the prodromic symptoms 
of the disease, a watchful observance of the condition of the patient in 
and after the paroxysm, will generally lead to a correct opinion within a 
few hours, or after a day, and sometimes at the moment of the attack. 
Of the eruptive diseases, scarlet fever is much the most apt to be accom- 
panied by convulsions at the onset, and in that disease the remarkable 
rapidity and activity of the pulse, the state of the fauces, the coryza, heat 
of skin, and early appearance of the eruption, will generally enable us to 
understand the cause of the convulsion at a very early period. 

The treatment of sympathetic eclampsia depending on acute thoracic 



LARYNGISMUS STRIDULUS. 443 

or abdominal disease, should be that which is proper for the particular 
malady which they complicate, with the addition of warm baths, revul- 
sives, antispasmodics, and, after depletion, of opium, in the form of 
Dover's powder combined with nitre. The management of the convul- 
sions which complicate the eruptive fevers, will be specially treated of in 
the articles on those maladies. 



ARTICLE II. 



LARYNGISMUS STRIDULUS. 



Definition; Synonymes; Frequency. — Laryngismus stridulus be- 
longs to the class of neuroses. It is characterized by crowing inspirations, 
or by momentary suspensions of the act of respiration ; these attacks occur 
suddenly, and at irregular intervals, are of short duration, cease suddenly, 
and are unaccompanied by cough, or other signs of irritation of the larynx. 
If the disease progress, it becomes associated with other convulsive symp- 
toms, as strabismus, distortion of the face, carpo-pedal spasms, or general 
convulsions. 

It is " the peculiar species of convulsion" of Dr. John Clarke ; the 
inward fits of Underwood ; the spasm of the larynx or glottis of Marsh ; 
the laryngismus stridulus of Good ; the croup-like convulsion of Dr. 
Marshall Hall; child-crowing; the spasme de la glotte of the French 
writers; and the thymic asthma of the Germans. It is not mentioned 
by Dewees. It is described by Eberle under the title of carpo-pedal 
spasms. 

The frequency of the disease seems to vary in different countries. In 
France it would appear to be rare. MM. Rilliet and Barthez speak of 
having seen but one case, and state that they are acquainted with only 
one other, published by M. Constant in the Bulletin de Thcrapeutique. 
M. Blache (article Nevrose du Larynx, Diet, de Med., t. xvii. p. 590) 
adverts very cursorily to one case. M. Valleix {Guide du Med. Prat. Art. 
Asthme Thymique) doubts its existence as a distinct disease. In Ger- 
many, on the contrary, it would seem to be a rather frequent disease. In 
England it cannot be very infrequent, since Merriman says it is by no 
means uncommon. Copland (Stridulous Laryngic Suffocation in Chil- 
dren, Diet, of Pract. Med.), speaks of numerous cases that he has seen, 
and states that he has had as many as three under treatment at the same 
time. Ley speaks of having met with considerably above twenty cases. 



444 LARYNGISMUS STRIDULUS. 

Dr. Marshall Hall remarks that " within the short space of one month, I 
have seen five cases of croup-like convulsion." 

I do not think it is a common disease in Philadelphia, though it is 
certainly not extremely rare, since I have seen one fatal case myself, and 
know of the occurrence of two others, and of two cases of recovery. 

Predisposing Causes. — Age. — It is generally acknowledged that the 
disease occurs most frequently during the period of the first dentition, 
though it has been known to exist as late as six or seven years of age. 
Of 20 cases (17 from authors, and three by myself), in which the age 
is given, 9 were six months or less of age, 6 between six months and a 
year, 3 between one and two years of age, 1 of two, and 1 of four years 
of age ; so that of the 20, 15 were under one year. It is evident, there- 
fore, so far as these cases go, that the majority occur within the first, and 
very few after the second year. 

Sex. — It is most frequent in the male sex. Of 49 cases (45 from au- 
thors, and 4 by myself), 38 occurred in boys, and 11 in girls. 

Constitution. — Authors who have written on the disease, generally ex- 
press the opinion that it is most frequent in delicate and feeble, and 
especially in scrofulous constitutions. It is nevertheless acknowledged 
that it sometimes occurs also in the most healthy and vigorous subjects. 
It not unfrequently attacks several children in a family. Ley quotes four 
instances from other writers, in which three children in each family had 
the disease, and in one all three died. He states that his own experience 
fully confirms this fact. 

Nature and Exciting Causes ; Forms. — Much difference of opi- 
nion has prevailed in regard to the nature and exciting causes of laryngis- 
mus stridulus, since the disease has attracted the particular notice of the 
profession. Kopp and other G-erman authors ascribe it to compression of 
the respiratory organs by enlarged thymus gland, while others of that 
nation, and some of the English and French writers, class it amongst the 
neuroses. Dr. Hugh Ley supposed it to depend on compression of the 
par vagum nerves by enlarged cervical and bronchial glands. Dr. Mar- 
shall Hall considers it to be a disease of the reflex system of nerves. 
Amongst the French writers, MM. Eilliet and Barthez regard it as a 
neurosis, consisting of spasm of the glottis j Valleix doubts the propriety 
of regarding it as a distinct disease ; Blache {Diet, de Med. t. xvii. p. 584), 
speaks of it as a neurosis of the larynx, which may be either symptomatic 
or idiopathic. 

Before examining in detail the different opinions quoted above, which I 
propose doing, I will refer to the anatomical appearances of the malady, 
as observed by M. Herard, in several autopsies made by himself {Bib. 
du Med. Prat. t. v. p. 319-320). 






causes. 445 

M. Herard states that lie found the mucous membrane of the air-pas- 
sages, as a general rule, perfectly healthy, presenting neither redness, in- 
flammatory swelling, oedema, nor accidental products of any kind. The 
lungs were of the natural color and density, and crepitant. They always 
presented one marked change from their natural condition, however, which 
was a very high degree of emphysema, more general and strongly marked 
than in any other disease. This alteration is believed to depend, as it 
does in hooping-cough, upon the impediment to respiration which exists 
during the disease. 

The heart and great vessels of the thorax often, but not always, con- 
tained more blood than usual, as in asphyxia. 

M. Herard states that he has made very minute researches in regard to 
the condition of the nervous system, examining the brain and spinal mar- 
row, the pneumogastric, recurrent, and diaphragmatic nerves, and those 
of the extremities even, to their terminations, without, however, finding 
important lesions in any case. He excepts only serous effusion in small 
quantity, and evidently consecutive, in the ventricles and particularly in 
the membranes of the brain, and slight venous congestion of the same kind. 
The tissues of the brain and spinal marrow retained their ordinary con- 
sistence, and presented neither redness nor softening. His researches in 
regard to the state of the thymus gland will be adverted to presently. 

I will now examine, as succinctly as possible, the different opinions 
which are advocated in regard to the causes of laryngismus stridulus. 
These may be classed, it seems to me, under four heads. 1. Enlarge- 
ment of the thymus gland ; 2. Enlargement of the cervical and bron- 
chial glands; 3, Organic disease of the cerebro-spinal axis; 4. That 
which regards it as a simple neurosis, without appreciable anatomical 
alterations. 

1. Enlargement of the thymus gland. — That the disease is often coinci- 
dent with, if not dependent upon, this cause, is proved by the observa- 
tions of Kopp, Hirsch, Haugsted, Kyll, and others. Hasse (Pathol. 
Anat. Syden. Soc. Ed. p. 384), says there can be little doubt that it 
sometimes depends upon this cause. 

It seems to me that it has been clearly shown by M. Herard (Loc. cit. 
p. 320, 321), that the disease is entirely independent of any alteration of 
the thymus. That observer found that in six children between two and 
four years old, dying of the affection, the gland weighed between half a 
drachm and a drachm in five, and four drachms and two scruples in the 
sixth. These cases alone show that the size of the gland varies greatly 
in different subjects attacked with the disease. M. Herard has examined 
the gland, with a view to the elucidation of this point, in sixty children 
dying with various diseases, between two and four years of age (the age 



446 LARYNGISMUS STRIDULUS. 

of those who had died of the disease under consideration). In fifty he 
found that it presented the same arrangement, color, density, and weight, 
as in those who had perished with laryngismus stridulus. All of these 
subjects presented the same aspect ) they were pale, thin, and most of 
them exhausted by diarrhoea. In ten of the sixty, the gland was 
much more voluminous, weighing from two to two and a half or five 
drachms, and in one instance an ounce and a quarter. The ten subjects 
upon which these observations were made died of different diseases, 
croup, acute laryngitis, asthma, meningitis, and varioloid. All presented 
the appearances of strong and vigorous health : the one which presented 
the largest gland was very fat, and so robust that though only twenty-two 
months old, he looked to be three or four years. It results therefore 
from these researches, that the gland is liable to great variations of size, 
and that its size bears a very exact proportion to the force of the child, 
being small in those who are slightly developed, or emaciated by chronic 
disease, and voluminous in those who are vigorously constituted, or who 
have died of acute diseases. 

That the disease does not depend, at least in all cases, on this cause, is 
shown also by Haugsted {Arch, de 'Mid. t. xxxiii. 1833, p. Ill), who 
reports the case of a girl, seven years old, in whom the gland weighed 
five ounces, and measured four inches long, and one and a half in thick- 
ness, without its occasioning the least difficulty of breathing of any kind. 
That it occurs in children in whom the gland is very small, is shown also 
by Caspari and Pagenstecher (quoted by Hasse, Loc. cit.) 

2. Enlargement of the cervical and bronchial glands. — This condition 
as a cause of the disease, so strongly advocated by Dr. Ley, and adopted 
upon his authority by Kyll and Hasse, would seem from certain facts and 
arguments to be of doubtful agency. 

Thus, Mr. Wakely (quoted by Kerr) states that " he possesses more 
than one case of tubercular affection in children, where the pneumogastric 
nerve has been completely flattened by the pressure of tubercles, without 
giving rise to any remarkable disturbance of the function of respiration." 
Dr. Hall doubts the correctness of this explanation of the phenomena of 
the disease, and says that if the contiguity of enlarged glands with the 
pneumogastric nerve have any effect, it is by their action upon it as an 
incident excitor, and not as a motor or muscular nerve. 

3. Organic disease of the cerebrospinal axis. — That it may depend on 
this cause is proved by a case mentioned by Dr. Coley ( On Infants and 
Children, Belt Is edition , p. 226), who states that in a fatal instance which 
occurred in his own family, the only morbid appearance found on dissec- 
tion was a large exostosis growing on the inner surface of the occiput, 
which compressed the cerebellum and produced chronic inflammation of 



NATURE — CAUSES. 447 

the dura mater. No disease was discoverable either in the cervical or 
thoracic glands. Dr. Kyll (Arch. Gen. de Med. t. xiv. 1837, p. 94) 
quotes a case from Dr. Corrigan, of Dublin, which had lasted three months, 
in spite of calomel, emetics, and antispasmodics. Attention was called by 
chance to the spinal column, when it was discovered that pressure over 
the third and fourth cervical vertebrae was very painful, and produced 
loud cries from the child. Two applications of four leeches, at an inter- 
val of two days, to that point, removed all the symptoms, and the child 
recovered perfectly. 

Dr. M. Hall (Diseases and Derangements of the Nervous System y 1841, 
p. 99) states that the crowing inspiration may arise from affections of the 
centre of the excito-motory system. He quotes a case related to him by 
Mr. Evans of Hampstead, of spina bifida, in which " there was a croup- 
like convulsion whenever the little patient turned so as to press upon the 
tumor." He states, moreover, that he found induration of the medulla 
oblongata in one case of the disease. 

4. That it is a neurosis. — This is the opinion, according to MM. Rilliet 
and Barthez, of Caspari, Pagenstecher, Roesch, and Hachman. It is that, 
also, of MM. Rilliet and Barthez, and, as we have already seen, of 
MM. Blache, Herard, and Dr. M. Hall. 

That the disease is, in fact, in the great majority of cases, a simple 
neurosis, is proved, I think, by the opinions just quoted, by the autopsies 
of M. Herard (already referred to), and by a case published by M. Con- 
stant, and cited by M. Blache (Loc. cit. p. 584). This was the case of a 
boy twenty-one months old, who was taken to the Children's Hospital at 
Paris, with well-marked symptoms of laryngismus stridulus, and who died 
there some days afterwards of small-pox. At the autopsy the larynx and 
brain were found to be healthy. Merriman also relates two cases in 
which the children died in fits, both of which were examined by a skilful 
anatomist, but "not the slightest appearance of cerebral affection" could 
be discovered. 

That it is not always, however, a neurosis, is also shown, it seems to me, 
by the cases quoted under the first head from Drs. Hall and Coley, and by 
those in which the disease is accompanied from the first by symptoms of 
inflammation or congestion of the brain. 

It has now been shown that the causes of the disease are exceedingly 
variable and uncertain, and that any opinion which asserts its dependence 
on one invariable and constant cause is untenable. We must, therefore, 
seek some explanation which shall reconcile, as far as possible, the facts 
related above, and harmonize the various opinions expressed by the authors 
quoted. 

It seems to me that the explanation given by Dr. Hall (Loc. ci*.), is 



448 LARYNGISMUS STRIDULUS. 

the only one which accounts satisfactorily for the phenomena of the disease, 
and reconciles the contradictory accounts of its nature and causes hitherto 
brought forwards. Dr. Hall regards it as an affection of the excito- 
motory or true spinal system of nerves, producing in mild cases partial 
closure of the glottis, and difficult inspirations, while in more severe cases 
the spasmodic disposition extends to other parts of the body, — to the eye- 
balls, and to the flexors of the fingers and toes. In very violent attacks, 
the glottis is entirely shut, the respiration is for a time suspended, and from 
the consequent impediment to the circulation, the nervous centres are 
violently congested, and general convulsions not unfrequently produced. 

The causes may be either centric, seated in the nervous centres, or cen- 
tripetal, in the excitor or incident nerves. In the great majority of cases, 
the causes are centripetal, consisting of various morbid conditions situated 
at the peripheral extremities of the nerves, which become causes in conse- 
quence of the irritation they establish in the nerve-extremities : this irritation 
is transmitted to the spinal centre, and thence reflected through the various 
efferent or motor nerves to the different portions of the muscular appa- 
ratus affected in the disease, the larynx, face, extremities, and lastly, in 
severe cases, the whole body. The principal causes of this class are 
dental irritation occurring during dentition ; gastric irritation, arising from 
excessive or improper food; intestinal irritation from constipation, intes- 
tinal disorder or catharsis ; and perhaps the pressure of enlarged cervical 
or bronchial glands. 

The centric class of causes includes such as are seated in the nervous 
centres. These are much less common than the former class, and give 
rise to a vastly more dangerous and intractable form of the disease. They 
are different morbid conditions of the brain and spinal marrow, as inflam- 
mation, congestion, and effusion. That such causes sometimes produce 
the disease is shown by the case of exostosis already quoted from Coley, 
that of spinal irritation from Kyll, that of Dr. Hall, in which he found 
induration of the medulla oblongata, and the one of spina bifida reported 
to Dr. Hall by Mr. Evans. In the latter case the tumor was seated on 
the loins. Mr. E. proposed to treat it by compression, but on making the 
attempt, found that it was followed immediately " by the affection described 
by Dr. J. Clarke" (Hall, Loc. cit. p. 144). Other centric causes are pas- 
sion, vexation, fright, contradiction, &c, &c. 

This theory of the nature of the disease likewise accounts for the vary- 
ing character of the convulsive symptoms. The laryngeal spasm, from 
which the disease derives its name, does not constitute the whole malady ; 
it is only one of the symptoms, though the principal one, and that by 
which it is particularly characterized. The other convulsive phenomena, 
which generally occur only in severe attacks, or after the disease has con- 



SYMPTOMS. 449 

tinued for some time, are distortion of the face, strabismus, carpo-pedal 
spasms, and general convulsions. The hydrocephalic symptoms which 
occur towards the termination of some cases, and the serous effusion within 
the cranium found after death, are, it ought to be recollected, often the 
consequences of the congestion of the brain and asphyxia, which take 
place during the more or less complete closure of the larynx. 

Before proceeding to the description of the symptoms, I wish to make a 
few remarks on the forms of the disease. 

M. Herard (Loc. cit.) makes three forms, one, in which the spasm 
affects chiefly the larynx, to which he applies the term laryngeal, another, 
in which the diaphragm is principally affected, which he calls diaphrag- 
matic, and a third, which is a combination of the two just named. 

I shall describe but one form, under the title of laryngismus stridulus, 
but after concluding the history of the symptoms of that affection, I pro- 
pose to give a short account of another spasmodic disorder of the respira- 
tory apparatus, popularly known in this country under the appellation of 
" holding-breath spells," and consisting of a sudden and total arrest for a 
few instants, of the act of respiration. This is thought by Herard to 
depend upon total closure of the glottis, and by Dr. Ranking (Rank. Abst. 
Med. Sc.j July to January, 1848, p. 165) to occur during expiration, and 
to depend on spasm of the diaphragm. The latter gentleman states that 
he has seen the attacks frequently in two of his own children. It seems to 
me most probable that it depends on sudden spasm of all the respiratory 
muscles, and not of the diaphragm alone. My reasons for thinking so 
are, that the attacks do, as Dr. Ranking remarks, occur during expiration ; 
that they are unaccompanied by any sound, at the time ; and that when 
the spasm is over, the child instantly makes a full inspiration, unattended 
with stridulous sound, and generally bursts into a loud fit of crying, 
which would scarcely be the case, were there a disposition to spasm of the 
glottis. 

Symptoms ; Course ; Duration. — Laryngismus stridulus begins sud- 
denly with a paroxysm of difficult respiration. The larynx is contracted 
spasmodically, and the entrance of air into the lungs is either prevented 
or impeded. In most cases, the closure of the larynx is only partial, and 
the respiratory movement continues, but is accompanied by prolonged and 
difficult inspirations, which give rise to the crowing or stridulous sound, 
whence the disease derives its name. The crowing sound is generally 
heard several times in each paroxysm, owing to the repeated but only par- 
tially successful attempts at inspiration ; while in very violent cases it 
occurs only at the beginning and end of the accession, the respiration 
being entirely suspended in the middle period. At the same time the 
child presents an appearance of great distress. The body is thrown for- 

29 



450 LARYNGISMUS STRIDULUS. 






cibly backwards, the eyes are fixed and staring, the nostrils dilated, and 
the whole countenance indicative of great anxiety. If the paroxysm 
continues many seconds, the face becomes bluish, the extremities cold, and 
the fingers and toes contracted. After a few seconds, or a minute, or 
even longer, the spasm of the larynx ceases ; a loud, full inspiration takes 
place ; a fit of crying generally follows, and the child either very soon 
regains its usual spirits, or, if the paroxysm have been very severe, seems 
weak, languid, and drowsy, and returns more slowly to its ordinary con- 
dition. Between the paroxysms the child may seem perfectly well, and 
without the least disturbance of the respiration, or it will present the signs 
of the disorder which is the ultimate cause of the laryngeal spasm. 

The paroxysms are most apt to occur during sleep, or as the child is 
waking. They occur spontaneously, and are brought on by fretting or 
crying, coughing, fright, contrarieties, deglutition, by the sudden appli- 
cation of cold, and other sudden impressions. At the commencement of 
the disease they recur at rare intervals, and often attract little notice, but, 
as the case progresses, they become more frequent, and may amount to 
twenty or thirty in the day, according to Kerr. They sometimes cease 
entirely for some weeks, or even months, and then recommence. In a case 
attended by myself (reported in the Am. Jour. Med. Set., April, 1847, p. 
287), the attacks lasted eighteen days, occurring sometimes two or three 
times in an hour, and sometimes much less frequently. The child then 
recovered entirely for a period of seven months, when the disease returned, 
and after continuing for five days, caused the death of the child in one of 
the paroxysms. 

If the disease continues to progress, it almost always becomes asso- 
ciated with other spasmodic symptoms. The thumbs are drawn tightly 
into the palms of the hands, and the fingers clasped over them, which 
gives to the backs of the hands a swelled and tumid look. At the same 
time the toes are strongly flexed under the feet, and the insteps look 
swelled like the backs of the hands. Sometimes the hands are bent on 
the forearms, and the forearms on the arms. There is often distortion of 
the face. In severe cases, or when the disease has continued for a con- 
siderable period, epileptiform convulsions make their appearance, and 
generally prove fatal. 

The disease is apyretic in a large majority of cases. "When fever arises 
it almost always depends on the condition which has occasioned the dis- 
ordered action of the excito-motory system, or on some accidental com- 
plication. The pulse during the paroxysm is small, corded, rapid, and 
sometimes imperceptible. In the intervals it is natural or nearly so. 

Death may occur very early in the disease, or after some weeks, months, 
or according to Kyll, years. In a case communicated to me by Dr. Wm. 



' 






HOLDING-BREATH SPELLS. 451 

Pepper of this city, death occurred in ten hours from the commencement. 
In one quoted by MM. Rilliet and Barthez, it took place at the end of 
three weeks, and in another, in twenty months. 

The duration is very uncertain. It generally, however, lasts several 
months. In Dr. Pepper's case, the duration was but ten hours. In my 
own case it lasted eighteen days, then ceased for seven months, returned, 
and proved fatal in five days. In another, the notes of which were 
obligingly furnished me by my friend Dr. Benedict, and which I shall 
append to this article, it lasted four months and a half, and was followed 
by perfect recovery. 

Holding -breath Spells. — This form of disorder is mentioned, so far as I 
know, only by MM. Rilliet and Barthez (t. ii. p. 255, 256), by M. He- 
rard, and by Dr. Ranking. I have met with a considerable number of 
well-marked cases of the affection, and believe it to be of quite common 
occurrence. It seldom happens that the physician is consulted in regard 
to it, as those who have charge of children in whom it occurs, almost 
always ascribe it to temper, and think it of but little moment. It appears 
to be the result of a sudden spasm of all the respiratory muscles, so that 
the child ceases for the time to breathe, from which circumstance, no 
doubt, it has received its name of holding-breath spell. There is no 
stridulous sound, nor hoarseness of the cry, nor indeed sound of any 
kind. The face is contracted and bluish, and the limbs violently agitated 
at first, and then stiff; after a few seconds, or perhaps a minute in severe 
cases, the spasm yields, and is followed either by loud crying, which lasts 
for a few moments, after which the child seems perfectly well, or else it 
is followed by excessive paleness, with languor or prostration, lasting half 
an hour, or even longer. The attacks recur with variable frequency ; 
there may be several in a day, or but one, or they may occur only at 
intervals of several days. The most frequent cause of the paroxysms is 
contradiction. They are determined also by fright, pain, and crying. 
They never occur spontaneously, and never during sleep, so far as I know. 
It is to be distinguished from laryngismus stridulus by the absence of the 
crowing sound, by its not occurring spontaneously or during sleep) and 
by the absence of carpo-pedal or other spasmodic symptoms. It is, I 
believe, a spasmodic affection of respiration, analogous to, though not 
exactly similar to laryngismus stridulus. I have never met with it except 
during the period of the first dentition, and always in children of nervous 
temperament. The cases that I have met with all recovered, and in one 
only did the life of the child seem to be at all endangered. In this in- 
stance the paroxysms had recurred very frequently for eleven months, 
and on two occasions were terminated by slight spasmodic movements of 



452 LARYNGISMUS STRIDULUS. 

the limbs, lasting only for a few instants, and unaccompanied by insensi- 
bility or other dangerous symptoms. After these attacks the child was 
removed to the country, where he recovered perfectly. 

Diagnosis. — The only disease with which laryngismus stridulus is 
likely to be confounded is spasmodic laryngitis, or false croup. From 
this it may readily be distinguished by the absence of catarrhal symptoms, 
or fever ; by the fact that the paroxysms occur indifferently in the day 
or night, and that they are much more frequent ; by the absence of cough 
or hoarseness of the voice, even during the height of the paroxysm ; by 
the occurrence of tonic muscular spasms, and convulsions ; and finally by 
the chronic course of the malady : the converse of all of which symptoms 
exists in spasmodic croup. 

Prognosis. — The prognosis of the disease is always serious, since even 
the mildest cases may terminate fatally at any moment in one of the pa- 
roxysms. It is, however, far from being so dangerous a disease as has 
been supposed by some writers, and amongst others M. Valleix, who states 
that it is almost always fatal. (Guide du Med. Prat. t. i. p. 564.) Of 
56 cases collected from Pagenstecher, Hachman, Ley, Kopp, Hall, Con- 
stant, Rilliet and Barthez, Kyll, and 5 from my own observation, making 
61 in all, 4 died of intercurrent or consecutive diseases, while of the re- 
maining 57, 32 were cured, and 25 died of the malady itself. 

The prognosis given by the physician ought to depend in great measure 
upon the cause of the malady. When it depends on dentition, improper 
diet, or gastro-intestinal disease, the case will in all probability terminate 
favorably if a proper treatment be directed against those morbid condi- 
tions ; while if it occur under the influence of a centric cause, or of en- 
largement of the cervical or bronchial ganglions, the prognosis becomes 
much more unpromising. 

Treatment. — If the views taken of the nature of the disease in the 
above remarks be correct, it must be evident that for the treatment to 
offer any considerable chance of success, it must be directed not merely to 
the removal of the spasm of the larynx, which is only a symptom and 
not the whole disease, but to the remedying of the deeper-seated cause 
of the disordered functional action of the excito-motory system of nerves. 

When dentition is ascertained to be the cause of the attacks, the gums 
ought to be carefully watched, and freely scarified, so soon as there is the 
least heat or swelling over the advancing teeth. Dr. Marshall Hall 
deems the use of the gum-lancet one of the most important means of 
treatment we are possessed of, and recommends that the gums should 
be fully divided, " not once, or occasionally, but twice, or even thrice, 
daily/' In another place, he says : " We should lance the gums freely 
and deeply, over a great part of their extent, daily, or even twice a day, 



TREATMENT. 453 

and apply a sponge with warm water, so as to encourage the flow of blood. " 
He even recommends that in very urgent cases, the lateral as well as the 
more prominent portion of the gum, should be scarified. I would, how- 
ever, call the attention of the reader to the circumstance, that when the 
operation of lancing the gum is performed while the tooth is still soft and 
enclosed in its sac, it is apt to be injured should it be touched by the lan- 
cet, so that it makes its appearance at last with a defect which causes an 
early and rapid decay. This, to be sure, is no argument against an ope- 
ration which may save the life of the child, but it should lead us, it seems 
to me, not to cut deeper into the gum than is absolutely necessary, and to 
avoid, if possible, the tooth, while it is still in a soft state. 

When the disease depends on gastric irritation, the result of an unhealthy 
milk, or of artificial diet, our attention must be directed principally to the 
removal of those conditions. A wet-nurse ought to be procured at once 
if one can be obtained, and if the child will nurse. If this cannot be done 
the diet must be carefully regulated by the physician. Ass's milk or 
goat's milk ought to be used if they can be procured ; if not, I would re- 
commend the gelatine diet prepared as recommended at page 262. The 
proportion of the ingredients must be regulated by the condition of the 
stomach. If the digestive power be very weak, the proportion of milk 
must be only a fourth or even a sixth for a few days, while the amount of 
cream must bear its usual ratio to the milk. 

When the child is thin and pale, and the stomach evidently weak and 
dyspeptic, it is well to resort to small quantities of stimulants, and to 
tonics in proper doses. The best stimulant is fine old brandy, of which 
from five to ten drops may be given three or four times a day, or every 
two or three hours. Or we may administer the aromatic spirits of harts- 
horn in connexion with, or without the brandy ; of this about ten or fif- 
teen drops should be given four or five times a day, or alternately with 
the brandy. Of tonics the most suitable, it seems to me, are quinine, in 
the dose of a quarter of a grain three or four times a day, or the citrate 
of iron and quinine, in the dose of half a grain, given in the same way. 
Another very excellent stimulant and tonic is the Huxham's tincture of 
bark, of which about five drops may be prescribed in the place of brandy. 
This kind of treatment will scarcely fail to stimulate the digestive power 
of the stomach to greater activity after a few days, and of course to im- 
prove the nutritive function and strength of the patient. 

When the disease appears to depend on intestinal irritation, we must 
inquire carefully into its nature and causes. It may be connected with 
constipation, diarrhoea, or with an unhealthy state of the contents of the 
bowels. It is often dependent on the presence of crude or imperfectly 
digested food in the digestive tube, and when this is the case, the only 



454 LARYNGISMUS STRIDULUS. 

proper method of treatment is to attend to the stomach and to discover and 
employ some diet that can be digested. The stools are often found to be 
very offensive, light-colored, and pasty, conditions generally resulting from 
imperfect action of the liver. Under these circumstances small doses of 
mercurials, or taraxacum, should be resorted to in combination with or 
followed by mild aperients, as castor oil or rhubarb. When diarrhoea 
is present, it must be treated according to its causes, as recommended in 
the articles on simple diarrhoea and entero-colitis. When, on the contrary," 
constipation appears to be the cause of the disorder, it is to be treated by 
regulation of the diet, by the daily use of warm water enemata (particu- 
larly recommended by Dr. M. Hall), or, if these do not answer, by the 
exhibition of small doses of the mildest aperients. 

Dr. Hall states that by strict attention to dentition, and to gastric and 
intestinal irritation in the dawn of the disease, he has succeeded in curing 
all the cases he has seen but one, and in that he found induration of the 
medulla oblongata. 

By those who suppose the disease to depend on enlargement of the 
thymic, cervical, or bronchial glands, it has been proposed to endeavor to 
procure a reduction of the hypertrophy by frequent applications of leeches, 
by the use of exutories upon the thorax, by the employment of strong 
purgative medicines, and by the administration of mercury, digitalis, and 
iodine. In a case apparently connected with enlargement of the bronchial 
or cervical glands, I would prefer to direct my treatment to the invigora- 
tion of the general health by attention to diet, by the use of tonics, and 
by proper exposure to fresh air, whilst I would employ internally, anti- 
spasmodics and preparations of iodine. 

When the disease depends on a centric cause, this must be treated, if it 
can be detected, according to its nature. 

Antispasmodics. — Whatever be the causes of laryngismus stridulus, it is 
undoubtedly proper, whilst our chief efforts are directed towards their re- 
moval or mitigation, to make use of antispasmodics in order to moderate the 
spasmodic symptoms which are the expressions of those causes. The reme- 
dies of this class most highly recommended are cherry-laurel water, valerian, 
musk, assafcetida, oxide of zinc, and small doses of ipecacuanha. The most 
efficient are probably the oxide of zinc, which is recommended by M. Bra- 
chet {Traite Pratique des Convulsions dans V Enfance) as one of the best 
antispasmodics that can be used in the convulsions of children, the fluid 
extract of valerian, and aromatic spirits of hartshorn. M. Brachet always 
combines the oxide of zinc with extract of hyoscyamus, and gives at least 
two grains of the former with four of the latter, in divided doses, in the 
twenty-four hours. He states that he has never given more than ten 
grains of each in the period mentioned. Of the fluid extract of valerian, 



TREATMENT. 455 

about a teaspoonful, or even more, might be given in the twenty-four hours, 
to a child one or two years old. It should be mixed with water, of 
course. The aromatic spirits of hartshorn may be given as recommended 
above. 

It must never be forgotten, however, that remedies of this class are 
to be employed only as palliatives and adjuvants, and not as curative 
agents. 

Treatment during the paroxysm. — When the child is attacked with 
a paroxysm of difficult breathing, it should be lifted at once into a 
sitting posture, if it be reclining, and fanned, or carried to an open win- 
dow, if the weather be not too cold. At the same time, a little cold water 
should be sprinkled upon the face, and if the attack be violent, we may 
resort to what is recommended by Dr. Hugh Ley and Dr. Hall, tickling 
of the fauces to produce nausea or vomiting, or irritation of the nostrils 
with a feather, so as to occasion gasping respiration. In a case which 
occurred to my father, Dr. C. D. Meigs, accompanied with severe general 
convulsions, he found that the suspension of the respiration could very 
generally be broken in upon, and the paroxysm sometimes averted, by the 
application of a piece of ice wrapped in a cloth, to the epigastrium and 
lower part of the sternum. 

To prevent congestion of the brain and effusion, which sometimes takes 
place as the effects of the attacks, Dr. Hall recommends a few leeches or 
cups to the head, the application of an alcoholic lotion over the whole 
head, or the use of the ice-cap. At the same time the bowels ought to be 
speedily moved by large enemata, either of simple water, or of water con- 
taining salt. 

Removal to the Country. — When the disease persists, in spite of the 
means above recommended, and especially when it depends on dentition 
or digestive irritation, change of air will often produce a wonderful effect, 
and should always be tried. The good effects of removal from the city 
to the country are strikingly shown in the case communicated to me by 
Dr. Benedict. 

CASE COMMUNICATED BY DR. PEPPER. 

"A boy aged four months, remarkably healthy and well-developed, 
after suffering a few days with slight catarrhal symptoms, was suddenly 
seized with a peculiar stridulous crowing respiration. 

"I saw the child about half an hour from the commencement of the 
attack, and found it with a pulse of 140, pale face, and livid lips. The 
pupils were contracted and the hands firmly clinched ; the crowing sound 
was very loud, and attended every act of inspiration. At times the respi- 
ration and circulation would be entirely suspended for many seconds, 
followed by great lividity of the surface, and coldness of the extremities. 



456 LARYNGISMUS STRIDULUS. 

" Eight or ten leeches were applied behind the ears, the feet placed in 
warm water, and a dose of 01. ricin. administered, to be followed by saline 
enemata. 

" Four hours from the commencement of the attack, all the symptoms 
were greatly aggravated ; the wrists and fingers were firmly flexed, these 
spasms coinciding with the arrest of the circulation and respiration ; there 
was now perfect insensibility. The child was placed in a warm bath, 
cold was applied to the head, and a sinapism along the spine, without, 
however, affording any relief to the crowing inspiration, or other spas- 
modic symptoms. 

" At the suggestion of Dr. C. D. Meigs, the child was now placed on 
its right side, with the shoulders elevated ; this position to be maintained 
at least six hours. At the end of that time the child was in no respect 
improved, and accordingly, at the suggestion of Dr. M., six leeches were 
applied over the cardiac region; Ji of lac assafoetid. was thrown into the 
rectum, and a blister applied to the back of the neck. 

" The child expired at midnight, about ten hours from the commence- 
ment of the attack, the crowing respiration, with more or less asphyxia, 
having persisted throughout. 

" Autopsy thirty-six hours after Death. — Mucous membrane of larynx 
injected, but in other respects natural. Thymus gland 3£ inches long, 
2 i wide, and at its upper part f of an inch thick. Weight, 620 grains, 
or ten drachms and one scruple. Lower lobes of both luugs greatly 
congested. Heart natural. The brain unfortunately could not be ex- 
amined." 

Remarks. — It seems to me that the above case was clearly one of 
laryngismus stridulus, dependent upon a centric cause, probably conges- 
tion of the cerebellum or medulla oblongata. It was, in fact, a case of 
what is called by M. Valleix " eclampsia with suffocation." Neverthe- 
less, violent general convulsions, attended with crowing respiration from 
the first, are very rare ; and the above case is curious as an instance of 
that kind. I would particularly call the attention of the reader to the 
marked signs of asphyxia that were present, which condition conduced, 
of course, very much to the rapidly fatal termination. 

CASE COMMUNICATED BY DR. BENEDICT. 

u The subject of this case was a boy born in July, 1845. He was a 
large, hearty child, and remained well until January, 1846, when his 
mother's milk failed, and he was placed upon artificial diet. From this 
time to May following, his diet was cream and water, barley-water, oat- 
meal, arrow-root, pounded crackers boiled with water, and gum water, 
all of which were tried in turn, being prepared and administered with 



case. 457 

the greatest caution, as to time and quantity. A wet-nurse was tried, 
but the child refused the breast entirely. 

" On the 27th January, he was attacked with diarrhoea which lasted 
one week. This was followed by constipation, the stools being white, 
firm, tenacious, and offensive. The constipation continued up to July, 
when it was replaced by diarrhoea. 

" February 4th, 1846. — On this day, the child being seven months old, 
was first observed a spasm of the larynx, producing a shrill, croupal 
whistle, or ooh, ooh, during two or three successive respirations, and fol- 
lowed by a cessation of breathing for some seconds, long enough to dash 
water in his face, carry him to the window, pat him on the back, &c. 
These spells occurred during the sleeping and waking state, and especially 
during crying or laughing, and continued almost daily and often many 
times a day and night until June, when he was taken into the country. 

" Simultaneously with the laryngeal spasm, appeared contractions of 
the upper extremities, the thumbs being drawn tightly into the palms of 
the hands, the fingers flexed over the thumbs, and the hands bent on the 
forearms. The backs of the hands were swollen, and the skin looked 
tight and polished. 

" For a few days in the middle of February there was a subsidence of all 
the symptoms, with decided improvement in every respect. 

" On the 25th of the same month, occurred a return of all the symp- 
toms, with extension of the spasm to the feet, the toes being bent under 
the feet, the insteps much swelled and having a polished appearance. At 
the same time there were occasional spasmodic movements of the muscles 
of the face, arms, and body, resembling those of chorea. This condition 
continued with occasional relaxations up to the 11th of June. 

" The stomach was exceedingly delicate, rejecting the most carefully 
selected nourishment, and at times refusing all food. The child became 
pale, thin, and timid, was disturbed by the slightest noise, and shunned 
the light as painful. 

" He was removed to the country on the 11th of June. There his 
health was gradually restored. The appetite improved, the spasm of the 
larynx and contractions of the extremities gradually relaxed, and the 
thumbs were at last liberated, the skin under them having taken on the 
appearance of mucous membrane. There was no return of the disease 
after the middle of June, although the child had a severe attack of diar- 
rhoea in July, after which he got perfectly well, and has remained so up 
to the present time (June, 1847). The first tooth made its appearance 
in September, and he now has fourteen, and has cut them all without the 
least accident. During the last eight months he has been remarkably fat 
and hearty. 



458 LARYNGISMUS STRIDULUS. 

" I am not aware that any medicine had any effect in removing the 
disease. Calomel in large and small doses, antispasmodics of all kinds, 
frictions over the spine, blisters to the back of the head, alteratives, laxa- 
tives, &c, were persevered in without benefit. On removing him to the 
country, and feeding him on milk warm from the cow, at first diluted, and 
afterwards pure, an improvement was speedily observed." 

Dr. B. adds : " There cannot, I think, be any doubt that the disease 
originated in the stomach, and extended to the bowels, perhaps the liver, 
and to the nervous system." 

Remarks. — The above case was evidently one of laryngismus stridulus, 
as that disease is described by different medical writers. It must be clear 
to every one, I think, that the cause was seated, as Dr. Benedict remarks, 
in the digestive apparatus. The history of the case, the onset of the 
disease soon after the child was put upon artificial diet, the difficulty of 
finding food to agree well, the condition of the bowels, the offensive, bile- 
less stools, the persistence of the case so long as the stomach continued 
feeble and the food improper, and the rapid improvement after the child 
had felt the tonifying influence of the country air, all seem to me to show 
conclusively that the difficulty was in fact disordered digestion. 

I would recommend those who wish to observe still farther the influence 
of disordered digestion in the production of nervous disease, to peruse 
three cases detailed by Dr. Coley {Pract. Treatise on the Dis. of Children, 
Bell's edition, pages 233, 234, 235). 

CASE BY THE AUTHOR. 

The following case is one that I met with myself. I extract the fol- 
lowing account of it from a paper on croup. (Am. Journ. Med. JSci., 
April, 1847.) 

The patient was a girl, five months of age. I saw the child first on 
the 28th of March, 1844. The first attack occurred the day before I was 
called, but as the mother supposed it to be a matter of little conse- 
quence, she did not send for me until the next day. The child was well 
grown, and except a rather too great paleness, looked strong and healthy. 
It was playful and good-humored, nursed freely, had no fever, and between 
the paroxysms presented the appearances of perfect health. The parox- 
ysms occurred frequently in the course of the day and night, sometimes 
two or three times in an hour, or not so often. They often waked the 
little thing suddenly from tranqu t il sleep. The paroxysm consisted of a 
succession of long and difficult inspirations, accompanied by a peculiar 
whistling or crowing sound, such as might be supposed to depend on the 
passage of air through a narrow aperture. During the attack, the face 
assumed an expression of great anxiety, the respiratory muscles con- 
tracted with violence, and there seemed to be for the time imminent 



case. 459 

danger of suffocation. After several seconds or a minute, the shrillness 
of the sound diminished, the struggling subsided, and soon the respiration 
became perfectly natural, and the child seemed well. The paroxysms were 
usually followed by fits of crying, which, however, were easily pacified. 

The paroxysms gradually diminished in frequency and violence, and 
ceased entirely after the 13th of April. The treatment consisted simply 
in careful attention to the general health, and in the frequent use of 
warm baths and mild nauseants. 

The child remained perfectly well, with the exception of a slight attack 
of cholera infantum, until the following November, seven months after, 
when the disorder recurred. Several paroxysms occurred between the 
12th and 17th of the month, but as they were slight and unattended by 
other symptoms of illness, the mother was not alarmed, and paid but 
little attention to them. On the 17th of the same month, the child was 
sitting on the floor amusing itself with some playthings. There were no 
persons in the room except young children. They saw the little thing 
stoop forward suddenly, as though in play, and did not regard therefore 
it immediately. As it remained in that position, however, they went to 
it, took it up, and found it dead. It had perished suddenly, no doubt 
in one of the paroxysms of crowing. 

An autopsy was made, in which the larynx and thoracic organs were 
examined, but nothing was found to explain the cause of the disease or 
the sudden death. 



ARTICLE III. 



CONTRACTION WITH RIGIDITY. 



This is the disease called by the French contracture. I shall treat of 
it as idiopathic contraction with rigidity. It has been little known until 
within a few years, and yet is clearly not a very rare affection in Paris, 
from the number of cases on record in different medical journals and 
works. I have met with but one well-marked example of it myself in 
this country. This case, of which I shall give a sketch at the end of this 
article, and the one of laryngismus stridulus communicated to me by Dr. 
Benedict, and appended to the article on that disease, furnish very good 
examples of contraction coexisting with the former affection. 

The disease is evidently one of the forms of eclampsia, which assumes 
such a variety of shapes during infancy and childhood. Though it gene- 



460 CONTRACTION WITH RIGIDITY. 

rally exists as an idiopathic and distinct malady, it is in other cases asso- 
ciated with, or follows laryngismus stridulus or spasm of the glottis, and 
in others again, is combined with attacks of general convulsions. 

Definition. — By idiopathic contraction with rigidity (contracture of 
the French writers), is meant the involuntary tonic contraction of different 
flexor muscles of the extremities, particularly those of the fingers and 
toes, but sometimes of the forearms and arms also, existing independently 
of organic disease of the cerebro-spinal axis. It has been described by 
different English writers in connexion with laryngismus stridulus, under 
the title of " carpo-pedal spasms," " cerebral spasmodic croup/' " croup- 
like convulsions," etc., etc. I believe, however, that it will be useful to 
describe it separately from that disorder, for though of the same nature, 
and sometimes associated with it, it often exists as an independent 
affection. 

Causes. — It is most common between the ages of one and three years. 
It is much oftener sympathetic than essential, and its most frequent 
causes are difficult dentition, various diseases of the digestive tube, pneu- 
monia, bronchitis, masturbation, and unfavorable hygienic conditions. 
In some few cases, the disease is truly essential, since no pathological cause 
for it whatever can be detected. It is merely necessary to say that it is 
often symptomatic of disease of the brain, but of that form of the affection 
nothing will be said in the present article. 

Nature op the Disease. — It appears to consist in a functional 
derangement of the true spinal system, occurring without any cause that 
can be detected ; or determined by the existence of some irritation affect- 
ing incident excitor nerves. I once saw a child two years of age, who, 
after a restless, uneasy night, presented in the morning tonic contraction 
of the flexors of all the toes of both feet, so that the insteps were swelled, 
and looked smooth and polished. There was no other sign of sickness 
except peevishness. Learning on inquiry that the bowels had been some- 
what constipated for several days, and that the materials of the scanty 
stools which had been discharged, were dark-colored and very offensive, 
I ordered a dose of castor oil containing two grains of calomel. The 
contraction continued unyielding until six o'clock in the afternoon, when 
a very copious, dark-colored, viscid, and offensive stool occurred, and the 
contraction immediately ceased. Here the cause of the contraction was 
evidently an accumulation of unhealthy faecal matter in the intestine, 
which, irritating certain sensitive cords of the excito-motory system, 
caused a reflex motor action that gave rise to permanent muscular con- 
tractions. In other cases the disturbance of the excito-motory system 
depends on the irritation of excitor nerves occasioned by the process of 
dentition, by indigestion, by diarrhoea, pneumonia, pleurisy, etc. In 



SYMPTOMS. 461 

other instances, again, to which the term essential must be applied, it 
seems to depend simply on general debility and anemia, which are well 
known to be productive of functional disease of the nervous system. 

Symptoms ; Course ; Duration. — The disease rarely attacks children 
previously in good health, but generally those already suffering from 
some disorder of the general health, or a severe local affection. When 
sympathetic, the first symptom noted is the contraction which constitutes 
the disease. When essential, on the contrary, the onset is sometimes 
marked by various nervous symptoms, such as giddiness, headache, or 
somnolence, which soon pass off, leaving the simple contraction with 
rigidity as the only disease. In most cases, however, the attack begins 
with the muscular contraction, which generally affects the superior ex- 
tremities first, and gradually extends to the inferior. 

When the disease is fully developed, the thumbs are drawn down into 
the palms of the hands, and the fingers, strongly flexed at the metacarpo- 
phalangeal articulations cover and conceal the thumbs. At the same time 
that the metacarpo-phalangeal articulations are flexed, the phalanges them- 
selves remain extended and the fingers are separated from each other. 
The contraction generally affects the wrist-joints also, so that the hands 
are strongly flexed upon the forearms, and in some rare cases the latter 
upon the arms. The disorder usually affects the inferior extremities like- 
wise, the toes being in a state of tonic flexion or extension, the foot rigidly 
extended upon the leg, and its point sometimes drawn inwards. The 
spasm very rarely extends to the knees. 

Children old enough to describe their sensations generally complain of 
stiffness in the affected parts, with more or less severe pains darting along 
the course of the nerves. The contracted muscles are hard and rigid to 
the touch, and sometimes enlarged so as to appear in strong relief 
under the skin. In slight cases the contractions can be overcome by 
very moderate force and without pain, whilst in those which are more 
severe, the attempt is difficult and productive of acute pain in the rigid 
parts. The backs of the hands and insteps present a swollen appearance, 
and the skin over these points is smooth and polished. In the case com- 
municated by Dr. Benedict, appended to the article on laryngismus stri- 
dulus, the skin under the thumbs had assumed the appearances of mucous 
membrane, from the long and close confinement of the member. 

In addition to the symptoms already enumerated, which are character- 
istic of the malady, there are others which require attention. The child 
is of course unable to walk or perform any prehensile movement. The 
intelligence and senses always remain perfect in simple, uncomplicated 
cases. The nervous system shows signs of disorder in the form of rest- 
lessness or languor, and irritability, with crying and peevishness. In the 
great majority of instances, these are the only nervous symptoms, 



462 CONTRACTION WITH RIGIDITY. 






though in some there are general or partial convulsions, strabismus, and 
diminution of sensibility. Of these the most frequent is convulsions, 
which generally come on a few days after the attack, or precede the fatal 
termination. In the case of Dr. Benedict, referred to above, there were 
occasional choreatic movements of the face, arms, and body. The simple 
disease is unaccompanied by any febrile movement, and the organic func- 
tions go on naturally. In the sympathetic form, on the contrary, we 
have the various symptoms of the disease which acts as the cause of the 
contraction, whether that be abdominal or thoracic. The most common 
train of symptoms, in young children, is probably that which accompanies 
gastric or intestinal derangement, dentition, &c. The course and dura- 
tion of the disease are very irregular and uncertain. When once developed 
it may last from weeks to months, either slowly increasing in severity, or 
remaining stationary for a length of time. As a general rule, after it has 
lasted for some time, it becomes intermittent, sometimes diminishing or 
even disappearing entirely for a period, then reappearing or increasing, to 
subside or cease again, and so changing without regularity or evident 
cause, until at last recovery gradually takes place, or death occurs from 
the concomitant disease, or in a paroxysm of convulsions. 

Diagnosis. — The only difficulty in the diagnosis of idiopathic contrac- 
tion is to distinguish it from symptomatic contraction, or that which de- 
pends upon cerebral or spinal disease. The kinds of cerebral disease 
which most frequently occasion contraction are tubercle of the brain, and 
meningeal hemorrhage. The distinction can generally be made with con- 
siderable facility, however, by attention to the various disorders of intelli- 
gence and sensibility, to the fever, constipation, vomiting, and different 
modes of invasion and progress which characterize the symptomatic form. 
The following table, taken from MM. Rilliet and Barthez, will assist in 
the diagnosis : 

SYMPTOMATIC CONTRACTION. ESSENTIAL CONTRACTION. 

Cerebral symptoms, special func- Similar cerebral symptoms, but only 

tional disorders (convulsions, strabis- in exceptional cases, sometimes accom- 

mus, dilatation of the pupils, &c), pre- panying, but never scarcely precedin 

ceding or accompanying the contrac- the contraction. 
tion. 

In many cases irregularity of the No irregularity of the pulse, 
pulse. 

Generally partial, and commencing Binary, commencing in the fingers 

usually in the elbows and knees, and and toes, 
in a single extremity. 

Almost always permanent. Remarkably intermittent. 

Prognosis. — The prognosis must depend on the cause of the malady. 
The contraction itself has no influence whatever on the termination. The 






TREATMENT. 463 

fatal termination has always resulted from the anterior or concomitant 
disease. Six cases observed by M. Barrier all recovered. The case com- 
municated to me by Dr. Benedict, which was connected with laryngismus 
stridulus, and one very severe one that occurred in my own practice, also 
terminated favorably. The prognosis is favorable, therefore, when the 
attack occurs in a child of naturally good constitution, and when the 
cause of the disease is not a permanent or incurable one. The possibility 
of the occurrence of fatal convulsions should always lead us to make a 
guarded prognosis. 

Treatment. — The treatment must depend on the circumstances under 
which the disease has made its appearance. When it occurs in the course 
of an acute local affection, the treatment must of course be that which is 
proper for the concomitant disorder. When it depends on dentition, or 
on gastric or intestinal derangement induced by improper diet, the treat- 
ment is the same precisely as that recommended for laryngismus stridulus 
dependent on the same causes. 

It may be stated that, as a general rule, all violent remedies, as bleed- 
ing, calomel except in very minute doses as an alterative, drastic cathar- 
tics, and blisters, can scarcely fail to be injurious, unless manifestly 
necessary in the treatment of the concomitant affection. 

It is proper in almost all cases to combine with the treatment already 
recommended, the employment of antispasmodic remedies, particularly 
when the contractions persist after the removal of the primary disease. 

The best remedies of this class are the warm bath, used every day ; 
orange-flower water ; the fluid extract of valerian; assafcetida, and cam- 
phor. The diet ought generally to be nutritious and strengthening, par- 
ticularly when the patient is weak and delicate. 

In conclusion, I may state that the treatment should be very much the 
same as that proposed for laryngismus stridulus, and I therefore refer the 
reader to that subject for more detailed information. 

CASE BY THE AUTHOR. 

The subject of this case was a girl nine months old. The parents were 
healthy persons, but the mother, owing to some idiosyncrasy, had made 
but a poor nurse for the preceding child, and I had strongly advised her, 
therefore, at the birth of this one, to give it a wet-nurse. This was not 
done, however, and it was found necessary to feed the infant a great deal 
from its birth. During the early months of its life it had some slight 
attacks of disorder of the digestive system, but being taken to the country 
for several months in the summer, it there improved very much. On 
being brought back to town I saw it, and found it pretty well developed, 
but very pale, and, on the whole, delicate-looking. It was still nursed by 



464 CASE OP CONTRACTION. 

the mother, but not to any very considerable extent, as it was obliged to 
be fed several times each day. The food consisted of different farina- 
ceous substances made with cow's milk. 

On the left forearm of the child there was situated a congenital aneu- 
rism by anastomosis, which had grown, by the age of nine months, to be 
as large as a five-cent piece. It was deemed necessary to remove this 
tumor, and, accordingly, on the 11th of January, 1852, a surgeon tied it 
with a needle and double ligature. The child bore the operation very 
well, was soon quieted, and was cheerful and ate well until the even- 
ing of the 15th, when it was attacked with fever, which lasted all night, 
and was accompanied with a good deal of cough and some gurgling in 
the fauces. On the following morning, at about 7£ o'clock, it had a slight 
convulsive seizure, lasting a few moments, and marked by stiffening of 
the body, and a staring expression of the eyes. In the middle of the 
day, it was seized again, and during that and the next day (17th), up to 
10 P. H.j it had twenty-four convulsions. These lasted from three to 
eight minutes each ; they were general, and consisted of flexions of the 
limbs, working of the face, and were attended with unconsciousness. 
There was no opisthotonos during the attacks, no extensions of the limbs, 
and no contraction of the jaw. Between the seizures, the child nursed 
perfectly well, sucked the finger, had no stiffness of the lower jaw, and 
was perfectly conscious. There was, during these two days, some fever, 
as the skin was too warm, and the pulse between 161 and 180. The 
respiration was more frequent than natural, there was a good deal of 
cough, some catarrhal rales in the chest, and also some gurgling in the 
fauces. The stools were scanty, pasty, and white. There was a well- 
marked but rather faint rash on the limbs, and trunk, like erythema or 
mild scarlet fever, and the lymphatic glands on both sides of the lower 
jaw were somewhat swelled, and quite hard. The treatment directed was 
one-sixth of a grain of calomel every two hours ', two drops of solution 
of morphia with five of fluid extract of valerian, to be given also every 
two hours; warm immersion baths, and mustard foot-baths. On the 
second day, blisters were applied behind the ears. 

On the 17th the child was better. There was no convulsion ; she no- 
ticed well, smiled a little, nursed heartily, and took some arrow-root 
water. 

During all this time the tumor in the arm was not at all inflamed. It 
was neither red, sore to the touch, nor swelled. It was suppurating slightly. 
Under the idea that the convulsions might depend in part on the opera- 
tion, and in order to promote suppuration, a warm poultice was kept con- 
stantly applied over the tumor. 

The child continued better, with the exception of slight angina and 
severe cough until the morning of the 22d, when it waked early, crying 



CASE OF CONTRACTION. 465 

violently as though in severe pain, and I found the fingers of both hands 
strongly flexed at the metacarpal articulation over the thumbs, which were 
themselves drawn into the palms of the hands. The phalanges, though 
bent, as just stated, at the metacarpal articulations, were stiffly extended 
at the phalangeal articulations, and at the same time separated from each 
other. The hands were flexed at the wrists. The toes were flexed, and 
the feet stiffly cramped at the ankles, and the insteps, as also the backs of 
the hands, looked swelled and cushiony. Any attempt to open the hands 
was painful and caused crying. The pulse was frequent and small, the 
skin pale, and very slightly too warm ; the intelligence was perfect. The 
jaw was open, and the act of sucking was performed, but with some diffi- 
culty. On the previous day the bowels had been opened three times, and 
on this day once ; the stools were scanty, pasty, and white. At 9 A. M., I 
ordered, 

K. — Sol. Morph., gtt. ii. 

Ext. Valerian. Fluid., gtt. v. 

Lac. Assafoetid., gtt. xx. — M. 

To be repeated every hour or two. 

4 p. M. — Same state, except that the contraction is stronger. There is 
more heat of skin, much crying, and a restless, distressed motion of the 
head. At 4 J o'clock, two drops of laudanum were given with assafoe- 
tida. A teaspoonful of the following mixture was ordered every hour : 

R. — Mass. Hydrarg., gr. iii. 

01. Ricini, ^iii. 

Syr. Rhei. Aromat., £v. — M. 

10 P. M. — Has taken three doses of the mixture and had one large, 
whitish, pasty stool. Much easier. Has slept a good deal. Contractions 
not so strong, as the hands can be opened more easily and with very little 
pain. Skin soft, of natural temperature, and moist. Ordered one or two 
more doses of the mixture, and a repetition of the laudanum and assafce- 
tida, in case of restlessness. 

During all this time the tumor has not separated. A process of ulce- 
ration is going on around the ligatures, but there is no inflammation of any 
consequence ; the arm is not swelled, and there is neither redness nor 
soreness to the touch. 

January 30th. — The contracture diminished very much for two days, 
and then returned, so that during the 27th, 28th and 29th, it was very 
marked, the forearms being flexed on the arms, and the hands strongly 
flexed on the forearms. The feet also were very stiff, and strongly flexed. 
The head was occasionally but not constantly, retracted upon the trunk. The 

'30 



466 CASE OF CONTRACTION. 

child evidently suffered very much, as it cried constantly and was very 
restless, except when under the influence of anodynes or antispasmodics. 
The bowels are sluggish, but have been kept open by the oil and rhubarb 
mixture. The dejections were generally whitish and pasty, but occasion- 
ally there was a healthy yellow stool. On the 28th the following mixture 
was ordered. 



. — Ext. Valerian. Fluid., . . . 


& 


Liq. Anodyn. Hoffm., . . . 


5 SS - 


Liq. Morph. Sulph., . . . 


gtt. Ix. 


Syr. Tolutan., 


3 vi - 


Aquse, 


gii— M. 



A teaspoonful to be given every hour or two, when there is much suffering or 
restlessness. 

On the evening of the 29th, the ligatures were removed, as they had 
become entirely loose, though without cutting off the tumor. The dis- 
eased point was not much inflamed, nor was it very tender. 

The child is still nursed and fed. Since the 29th it has had goat's in- 
stead of cow's milk. On the evening of the 30th, the patient was more 
tranquil, the expression was more placid and open, and the contracture 
not quite so strong. 

Up to February 7th, there was no decided change in the symptoms. 
They continued quite as severe as before. The dyspeptic symptoms, the 
torpid state of the bowels, the want of appetite, and the white, pasty state 
of the evacuations were never relieved, except momentarily, by means of 
cathartics. On the 7th a wet-nurse was procured, but only after the most 
persevering and reiterated solicitation and insisting on my part, I having 
long been convinced that the cause of the contracture lay in the disordered 
state of the digestive functions, produced and kept up by the necessity of 
using artificial diet, and perhaps by an unhealthy state of the mother's 
milk. The parents, however, had always thought that the operation had 
been the cause of the convulsive disease, and for a length of time would 
not listen to a wet-nurse. 

After the child had been suckled by the wet-nurse for two days, tl 
stools, which, since the beginning of the sickness, now twenty-three days 
and to a greater or less extent, since birth, had been very unhealthy, bt 
came yellow, homogeneous, and natural in character ; while the bowels, 
instead of being obstinately constipated, so as to require large doses oi 
cathartic medicine, were moved spontaneously two or three times a day. 

On the 10th I noticed strong divergent strabismus, and the child looked 
very badly. The left leg was drawn up, whilst the right was stiffened. 
The left arm was more used than the right, the left hand being carried 
often to the mouth, while this was never done with the right. It was difli- 



CASE OP CONTRACTION. 467 

cult to measure the degree of the intelligence, but the child occasionally 
looked at and evidently noticed objects, but during most of the time it was 
dull and inattentive. 

On the 13th, there was an evident improvement, the previous night hav- 
ing been very good. The face was improved in color and expression, and 
was not quite so thin. The contracture was about the same. 

14th. — Some diminution of the contraction, the forearm being a little 
extended upon the arm, and the wrists, though still very rigid, not quite 
so much drawn. The child looks better; she nurses a great deal, taking 
all that the mother has, and most also of what the wet-nurse, a hearty 
woman, has. 

February 20th. — Doing very well up to last night, when she became 
more restless, cried a great deal, rolled the head on the pillow, and had 
slight retractions of the whole trunk of the body. Occasionally she 
ceased to cry, scarcely breathed, and had the eyes rolled upwards and 
fixed for several seconds. She looked pale and pinched again and refused 
to nurse. Had one whitish, curdy stool. Ordered two grains of mercury 
with chalk at once, and two hours afterwards a teaspoonful of castor 
oil. Both of these doses were rejected by vomiting. Half a grain of the 
mercury was then given, which was also rejected. A quarter of a 
grain was now given, and this with another dose was retained. During 
the night, the bowels were moved several times, and the discharges looked 
better, after which she nursed a little. 

21st. — Better; more quiet; nurses well. The boring with the head has 
ceased, as also the retractions of the trunk. One healthy stool. 

22d. — Much better; nurses well; one healthy stool. The contraction of 
the right arm is ceasing, and that of the forearm on the arm is gone on both 
sides. The left wrist is straight ; the right one is yielding very much though 
it is still somewhat bent. The fingers of the right hand, though still bent, 
have relaxed very much ; those of the left hand are still very much bent, 
but are less rigid than before. The integument of the palms of both 
hands, has become, in the flexures, whitish, soft, moist, mucous-like, and 
has an offensive odor. To-day and yesterday the child uses the arms, 
touches, and reaches out for articles ; she is much more intelligent, and 
looks at and observes objects ; she now holds her head up, and likes to be 
carried about sitting up in the arms of the nurse, which before she could 
not do at all. She is gaining flesh ; the color of the surface is improving ; 
the ears have become pink and pretty. 

A fresh assafoetida plaster was applied upon the back yesterday. 

March 1st. — Continues to do well. The right hand is to-day almost 
natural, being opened and shut, and used to grasp with, though it still 
looks a little stiff. Left hand much better; she opens and shuts the 



468 CASE OP CONTRACTION. 

forefinger, and grasps and hold toys with it, but the other fingers are still 
much contracted. The movements of the arms are quite easy and natural. 
There is no bending of the hands at the wrists, except perhaps very slightly 
in the left extremity. The feet are natural, excepting a slight stiffness. She 
now nurses very well, and is growing fat. She is larger, in fact, than 
before the sickness. The intelligence is improving rapidly, as she notices, 
smiles occasionally, and distinguishes, her attendants think, between per- 
sons. The bowels are regular without medicine. She has taken no re- 
medy of any kind for three days past. 

March 11th. — Almost entirely recovered. There is still a slight 'but 
only very slight, flexion of the fingers of the left hand. General health 
excellent. 

March 29th. — The patient is now perfectly well, except that she uses 
the forefingers of either hand rather better than all together, so that in 
grasping and holding an object, she is more apt to seize it with the fore- 
finger than with all. Still, she can, and does, seize it with all, when the 
object is large, and no one, unless very observant, would notice the pecu- 
liarity just described. Embonpoint very good ; complexion clear and 
healthy ; sleep sound ; bowels in excellent condition. Intelligence per- 
fect ; smiles and laughs a great deal, and distinguishes between persons ; 
takes a great deal of notice. She is about equal, in intelligence, to a 
child of eight months old. Does not attempt to speak. 

April 10th, 1852. — I was sent for to-day. The child had not been 
well for three days, having had three or four thin and greenish stools a 
day, with whitish specks in them. She was fretful and did not sleep well, 
and had a good deal of loose catarrhal cough and some acceleration of 
the breathing. I found her in the morning, after a restless night, quite 
feverish, hot and dry, with frequent respiration, and with some catarrhal 
wheezing in the chest. She had coughed a good deal, and her mother 
had found her hands showing some signs of spasm, the forefingers being 
extended as though pointing, and separated from the other fingers, which 
were flexed, with the thumbs also, into the palms of the hands. 

There is some degree of laryngismus, as on waking from sleep the 
breathing is labored, difficult, partially suspended, and accompanied with 
a slight crowing, or rather choking sound, while at the same time the face 
becomes pale and the mouth bluish. Bowels open three times yesterday, the 
stools being mucous, greenish, and containing small lumps of undigested 
caseum. 

Ordered a quarter of a grain of mercury with chalk diffused in a tea- 
spoonful of syrup of jalap, to be given every two hours. 

At 1 P. M., there was a slight general spasm, with stiffening of the 
limbs, and retraction of the head, lasting, however, only a few moments. 



CASE OF CONTRACTION. 469 

This occurred again in the afternoon. The dose of the mercury and jalap 
was reduced one-half in the middle of the day, as the quantity first ordered 
was found to cause sickness and vomiting. 

Evening. — Rather better. No fever ; some moisture of the skin; spasm 
of the hands very much relaxed. The diminished dose of mercury and 
jalap was well borne. 

11th. — Rather better. Some fever still, with cough, gurgling in the 
throat, and distinct enlargement and hardening of the lymphatic glands 
at the angles of the jaw on both sides. There is still some contraction of 
the hands. Bowels open freely twice last night, and the stools better, 
being of a pale yellow color, and more homogeneous. The jalap and 
mercury to be suspended. 

In the course of the day there were two slight general spasms, with 
laryngismus. The latter occurred several times during the waking state, 
but was not severe. Ordered three drops of syrup of ipecac, with four of 
sweet spirits of nitre, to be given every two hours. 

12th. — Much better. Contraction of hands almost gone ; very slight 
feverishness ; cough less frequent and looser; respiration easy. No 
spasm to-day. Stools more health)-, yellow, homogeneous, and of natural 
quantity. 

13th. — Continues better. Contracture slight. Cough diminishing very 
much. 

14th. — Rather pale, dull, and languid. Has had several attacks of 
laryngismus, one of which was quite severe, being attended with deep 
blueness about the mouth, and some of the face also. Does not nurse so 
well as formerly. The hands exhibit decided flexion of the third, fourth, 
and fifth fingers at the metacarpophalangeal articulation, with stiffened 
extension of the other phalangeal articulations. Thumbs slightly drawn 
into the palms, and the forefingers rather extended. Bowels natural. 
Ordered fifteen drops of brandy, and a very little of the Quevenne's me- 
tallic iron in powder, three times a day. 

15th. — Condition about the same. On the 22d of March, the first wet 
nurse, under whose charge the child had improved so rapidly, was changed, 
on account of some objection to her personal appearance, and another one 
procured in her place. This one was a healthy-looking woman, with milk 
enough, but she was red-haired, irritable, and excessively high-tempered, 
and the child has been gradually losing ground ever since her arrival. 
Under the idea that her milk did not suit the child, a third nurse was, by 
my advice, obtained to-day (15th), a calm, placid, fat, and comfortable- 
looking woman, with an abundant supply of milk of ten months old. 

17th. — The child has improved very much. She is fatter already, has a 
contented, tranquil expression, nurses more than she did from the previous 



470 CHOREA. 

woman, and rejects much less of the milk. The stools are now regular, 
occurring twice daily, without aid, and are of a natural appearance. The 
sleep of the child is better now than it has been at any time since the 
first wet nurse was sent away. The attacks of laryngismus are already 
much less frequent, and less severe. The hands are very nearly in a 
natural condition. The child is less nervous, not starting now as formerly 
at sounds. 

To continue the brandy and iron. 

From this period the child continued to improve regularly in health. 
She was removed to the country during the summer months, and when 
brought back in the autumn was entirely well, with the exception that 
she was less forward in walking than most children, but not more so than 
might have been expected in one who had been so dangerously ill for so 
long a time. Her intelligence was good in all respects. 

February 5th, 1853. — I have seen this child to-day, and find her in very 
good health, except that she is rather smaller in size than is usual at her 
present age. She has been weaned now for about six weeks, and eats heartily 
and digests well most ordinary food, as milk, meat, potatoes, &c. The 
weaning was borne very well, except that the appetite was rather deficient 
and capricious, for about a week after the departure of the nurse. She 
can stand up when placed in the erect position, and can walk feebly when 
well supported, but not alone, nor can she rise up from a sitting posture. 
Her intelligence is, in all respects, perfect, but she does not talk as yet. 
There is no vestige of her former spasmodic symptoms, when she is in 
good health; but any little turn of sickness reproduces some contraction 
of one leg, and a slight flexion of the hands. 



ARTICLE IV. 

CHOREA. 

Definition; Synonymes; Frequency. — Chorea is a non-febrile, con- 
vulsive disease, characterized by irregular and imperfectly co-ordinated, 
but not completely involuntary contractions of different parts of the mus- 
cular system, and particularly of the extremities. 

It is called also St. Vitus's dance, chorea sancti viti, choreomania, 
epilepsia saltatoria, and by various other titles. 

Without being very rare, chorea is certainly not of very frequent occur- 
rence. M. Rufz states that of 32,976 children admitted into the Chil- 
dren's Hospital of Paris in ten years, only 189 were affected with chorea, 



CAUSES — LESIONS — SYMPTOMS. 471 

or 1 in 377. (Diet, de Med., t. vii. p. 544.) I have met with but seven 
cases in private practice in the course of several years' experience. 

Predisposing Causes. — Age. — Chorea very rarely, some writers say 
never, occurs during infancy. M. Constant, however, reports a case at 
four months of age. According to M. Rufz, it is seldom met with be- 
tween one and six years of age, since of 189 cases, in only 10 did it occur 
within that period ; while between six and ten years of age it is much 
more common (61 in 189 cases) ; and between ten and fifteen years still 
more so (118 in 189). It is, therefore, much the most frequent about 
the period of puberty. 

Sex. — It is much more frequent in girls than boys. This is the expe- 
rience of all writers. 

Constitution does not seem to exert much influence in its production, 
though it is generally thought to be most apt to occur in children of deli- 
cate, excitable, and nervous temperament. The belief in hereditary pre- 
disposition seems to be unfounded. The disease appears to commence 
more frequently in summer than in winter, and yet it is scarcely known 
in tropical climates. 

Exciting Causes. — Of many exciting causes that have been mentioned 
by different writers, the one which seems most frequent and most clearly 
established, is the influence of terror. Besides this are cited imitation, 
blows and falls upon the head, fits of violent anger, contrarieties, mastur- 
bation, the difficult establishment of the menstrual function in girls, or 
suppression of that function, and the sudden drying up of ulcers or erup- 
tions. Various diseases have been thought to occasion chorea, particu- 
larly those of the gastro-intestinal tube. 

Anatomical Lesions. — It seems well established by the researches of 
many different observers that there is no characteristic anatomical altera- 
tion in chorea, since in a large majority of the cases examined after death, 
no lesion of the cerebro-spinal axis can be detected. In some few 
instances, however, lesions of those organs have been met with, the most 
frequent of which are inflammation of the tubercula quadrigemina, serous 
effusions, hypertrophy of the cortical substance of the brain, induration or 
softening of the spinal marrow, and other lesions. From these circum- 
stances, the disease has been divided, like convulsions, into idiopathic and 
symptomatic. 

Symptoms; Course; Duration. — The disease may be general or 
partial : in the first case it affects all the limbs, the face, and some of the 
muscles of the trunk ; in the second it implicates only one side, the upper 
extremities, or a single member. It has been asserted that often only one 
side was affected, and that in most of the cases it was the left. This is 
denied, however, by MM. Rilliet and Barthez, who state that they have 



472 CHOREA. 

met with but a single instance in which it was confined to one side through- 
out the attack. Of seven cases that I have seen, it was general in four, 
and confined entirely to the right side in one, and to the left in two. I 
shall describe first the prodromes of the disease, then the invasion, and 
afterwards the symptoms as they exist in fully developed cases. 

Prodromic Symptoms. — It is doubtful whether there are, as a general 
rule, any well-marked prodromic symptoms. The only ones that have 
been mentioned with any authority are irritability and peevishness of the 
temper, an unusual degree of impressibility, languor, debility, disturb- 
ance of the organic functions, exhibited by deranged appetite and an 
irregular state of the bowels, and, after a time, a certain quickness and 
irregularity of the movements, which mark the commencement of the 
characteristic symptoms of the malady. 

Invasion. — The onset of the disease is, as already stated, either sud- 
den or gradual, so that it may be several days or longer in reaching any 
considerable degree of severity, or it may, particularly when the cause has 
been of a sudden and energetic nature, reach its height in a few hours. 
In most cases, however, it begins with some unusual and singular move- 
ments in one of the upper extremities, and as a general rule in the left. 
The choreatic movements are often observed first in the fingers, and at the 
same time or soon after, in the face. Sooner or later they increase in 
severity, and extend to the other arm, to the legs, and to the tongue, and 
the disease is fully developed. 

Symptoms of confirmed general chorea. — At this stage the movements 
are exceedingly diversified and irregular. The limbs are agitated by 
involuntary contractions of the muscles into every attitude possible for 
them to assume. The fingers are opened and shut, brought together or 
separated, without any regularity. The hands are flexed and extended 
upon the forearms, or pronated and supinated, whilst the forearms are 
flexed or extended upon the arms, and the arms moved at the shoulders 
into every imaginable position. Such are the irregularity and rapidity of 
the movements that it is often with great difficulty that the patient can 
seize anything with the hands, and when once the object is attained, he 
frequently cannot do with it what he wishes. This imperfect control over 
the movements of the hands and arms sometimes prevents the patient 
from carrying food and drink to the mouth, excepting with the utmost 
difficulty, and may make it necessary to feed the child. 

The inferior extremities are affected with movements similar to those 
of the arms. Walking is always more or less difficult, and in some 
severe cases impracticable. The patient totters from side to side, or walks 
rapidly a short distance, and then suddenly stops. Sometimes the pro- 
gress is accomplished in a zigzag direction, and at others by fits and starts 



SYMPTOMS. 473 

as it were, whilst in others again, the walk is rapid and sudden, almost a 
run. The child often falls while walking or running, either from meet- 
ing a slight obstacle, or in consequence of the irregular and imperfect 
muscular action. In some instances standing is impossible, the knees 
bending suddenly under the weight of the body. It was no doubt the 
peculiar, irregular and dancing movements of the inferior extremities 
during the attempts to walk and stand, that gave to the disease its origi- 
nal name of St. Vitus's dance. 

The convulsive movements of the face and head are not less singular 
than those of the limbs. The face is distorted into all kinds of expres- 
sions, so that it assumes by turns that of the most opposite emotions, — 
sadness, terror, joy, or grief. The mouth is opened and shut, or its cor- 
ners drawn apart, with the greatest irregularity; the tongue is occasionally 
protruded between the teeth, and sometimes moved rapidly in the mouth, 
so as to cause a clacking sound; the lower jaw is depressed and elevated, 
or moved in a lateral direction, and with such violence perhaps as to in- 
jure the tongue or teeth. In consequence of the irregular motions of the 
tongue and mouth, articulation becomes difficult and the child either stut- 
ters, or speaks slowly and badly, or can pronounce only monosyllables. 
In a case that occurred to myself, the movements of the mouth and 
tongue were so violent and uncontrollable that the patient, a boy nine years 
old, lost entirely for three weeks the power of speech. He was at the same 
time unable to open or shut the mouth at will, or to swallow at the proper 
moment, so that in the act of feeding him, which was necessary from his 
entire want of control over the arms, the food was constantly spilled and 
spluttered about as though by an idiot. The act of mastication also was 
entirely impossible, and nothing but fluids, therefore, were taken for 
a number of weeks. Whilst the face and limbs are thus contorted, the 
head is moved rapidly from side to side, or backwards and forwards, or 
undergoes constant rotation. In severe cases the choreatic movements 
affect the trunk also, so that the patient cannot lie upon a bed, but rolls 
and twists about the floor with such violence as to bruise and excoriate 
the skin. Deglutition is sometimes slightly embarrassed, and the child 
is obliged to swallow with great rapidity ; in some few cases a peculiar 
loud cry, like that which occurs in hysteria, dependent apparently upon 
spasm of the larynx, has also been observed. The organic muscular 
apparatus is probably never affected with true choreatic spasms. 

The disease is unaccompanied by pain unless it be attended with some 
complication, and what is very singular and remarkable, the constant 
and often very violent muscular contractions do not seem to occasion 
fatigue. 

The general symptoms require some attention. The choreatic move- 
ments are almost always increased by emotion, as terror, anger, contra- 



474 



CHOREA. 



rieties, and by the consciousness of being observed. Sleep generally 
suspends them entirely. In very bad cases they are said to produce 
insomnia, or to wake the child .frequently in the night. The intelligence 
is rarely affected, except in very severe and long-continued attacks. The 
temper is often irritable and capricious. General and special sensibility 
commonly remain natural. In simple, uncomplicated attacks, the pulse, 
as a rule, remains natural ; the appetite is preserved ; there is no unusual 
thirst, and the bowels continue regular. 

It is said that idiocy is apt to occur in cases which last for a number of 
years. 

The course of the disease is acute or chronic. In a large majority of 
cases it is acute, the symptoms becoming more and more violent until 
they reach their height, when they remain stationary for a time, and then 
subside and disappear under the influence of treatment, or in the natural 
course of the malady. In fatal cases the symptoms are constantly aggra- 
vated; the movements become so violent as to make it necessary to secure 
the child in bed, or in a strait-jacket; the patients, deprived of sleep, 
become feeble and emaciated ; the respiration becomes difficult ; intelli- 
gence is abolished; the pupils are contracted; and the child dies. 

The duration is irregular, varying in acute cases between one and three 
months. The average duration is probably about six or nine weeks. In 
very slight attacks it may be much less. The duration of chronic cases 
is from months to years. In fatal cases the duration is sometimes very 
short. In one it was nine only, and in another twenty-seven days. 

It should not be forgotten that relapses are very common. 

Nature of Chorea. — Some doubt exists as to the nature of the dis- 
ease under consideration. That it is not an organic affection of the ner- 
vous centres is clear from the whole history of the malady, from the 
great variety of lesions found in some instances, and from the total absence 
of anatomical changes in others. Dr. M. Hall regards it as an affection 
of the true spinal system, but in this he is opposed, and I think, with 
reason, by Dr. Carpenter, who says (Principles of Human Physiol., Lond. 
note, p. 234) : " It is true that there is considerable irregularity in the 
ordinary reflex actions ; but the irregularity is still greater in those to 
which volition or emotion are the stimuli. Moreover, the body is at rest 
during sleep ; and the ' spinal system never sleeps/ " Dr. C. is disposed 
to think that the cerebellum, which is the organ which co-ordinates and 
harmonizes the muscular motions, is probably the chief seat of the disease, 
and this, it appears to me, is the most reasonable theory which has as 
yet been offered in regard to the real nature of the affection. 

Diagnosis. — The diagnosis of chorea cannot, it seems to me, be diffi- 
cult, and I shall therefore make no remarks upon it. 



PROGNOSIS — TREATMENT. 475 

Prognosis. — Idiopathic, simple chorea, independent of organic disease 
of the nervous centres, and of complications, is rarely fatal. Neverthe- 
less, even under these circumstances, it sometimes terminates fatally, 
since MM. Rufz, Legendre, and Eilliet and Barthez, have each met with 
an instance. When the disease, on the contrary, is occasioned by an 
affection of the brain or spinal marrow, it becomes very dangerous. The 
degree of danger will depend on that of the disease which determines the 
chorea. 

Dr. Copland states that he has met with three or four fatal cases, that 
Dr. Prichard has recorded four, and that Dr. Brown refers to three in 
his practice; but he does not inform us whether they were idiopathic, 
complicated, or symptomatic. 

Whenever, in a case of chorea, the convulsive motions become inces- 
sant, and the respiration embarrassed, and still more when subsultus 
tendinum takes the place of the choreatic movements, a fatal termination 
is greatly to be apprehended. 

Treatment. — Many different plans of treatment, and a great variety 
of drugs have been proposed for the cure of the disease under considera- 
tion. These facts alone may serve to teach us that the effects of treatment 
are not clearly appreciated, and also, when taken in connexion with the 
circumstance that fatal cases are rare, that the disease tends naturally to 
recovery in a good proportion of the cases. This feature of the natural 
history of the disease is shown also by the evidence given by Dr. Bardsley, 
senior, who mentions, that in the Manchester Infirmary, notwithstanding 
the variety of treatment adopted by successive practitioners, an incurable 
case had not presented itself in the course of thirty-three years. (Tweedie's 
Lib. Pract. Med., Am. Ed., vol. ii. p. 46.) 

It seems to me that the only rules to be laid down for its treatment 
are those which apply to all the convulsive affections depending on func- 
tional disorder of the nervous system. These are attention to the general 
health, the removal of any local derangement or disease that may exert an 
unhealthful influence upon the nervous system, and the employment of 
such remedies as have been found to exert a controlling effect upon spas- 
modic and convulsive affections generally, particularly antispasmodics. 

I shall consider, under different heads, the various means that have 
been recommended, endeavoring in the course of my remarks to distin- 
guish the cases to which each remedy is best adapted. 

Purgatives. — This class of remedies has been extensively employed, 
and often exclusively relied upon by some very high authorities, especially 
the English. When relied upon exclusively in the treatment, an active 
cathartic is given every day, or every second or third day ; and there 
can be no doubt that many cases have recovered under this plan. It 



476 CftOREA. 

seems to me, however, that they ought to be used, in general, only to 
such an extent as may be necessary to secure a soluble and healthful con- 
dition of the bowels. When, on the contrary, the stools are natural and 
healthful in all respects, it can scarcely be proper to employ powerful 
purgatives in the treatment of the disease. I would, therefore, resort to 
them only when there is constipation, or when the discharges present 
some unnatural appearances as to color, odor, etc. Under the latter cir- 
cumstances we may resort to any of the somewhat active cathartics, as 
cream of tartar and jalap, sulphate of magnesia, rhubarb, aloes, etc. 
When the discharges from the bowels are clay-colored, or dark and offen- 
sive, when the mouth is pasty, the tongue loaded with a thick yellowish 
fur, and the breath heavy, it is proper to employ a mercurial. Dr. Cop- 
land advises that we should commence with the exhibition of a full dose 
of calomel, either alone or with other purgatives, or followed by them in 
five or six hours. He adds that the doses of calomel ought not to be 
frequently repeated in the disease, and thinks that it is not serviceable 
" to continue purgatives long, without either exhibiting them with a bitter 
tonic or antispasmodic remedy, or with both, or alternating them with 
those remedies." 

Bloodletting can rarely be necessary or proper. The only circumstances 
that would seem to call for its employment, are severe headache, with 
signs of determination of blood to the brain, and the occurrence of the 
disease in a girl at the age of puberty, in whom there is reason to suspect 
that the cause of the disorder is the want of the menstrual function. In 
both these cases it is best to employ local bleeding ; in the first to the 
temples, or behind the ears ) in the last to the groins and upper parts of 
the thighs. It is proper to remark, however, that general bleeding has 
been recommended and practised by some most distinguished physicians. 
The evidence of late observers shows, nevertheless, that it is rarely, if 
ever, necessary, and there are many cases in which it could not fail to 
aggravate the already excessive excitability of the nervous system. 

Antispasmodics are amongst the most important remedies we have to 
oppose to the disease. The weight of evidence seems to show, indeed, 
that they, in conjunction with a moderate use of purgatives, and careful 
regulation of the hygienic conditions of the patient, ought to constitute 
the treatment in the great majority of cases. Of the various remedies of 
this class that have been employed, those which have exerted the most 
beneficial influence are valerian, assafcetida, oxide of zinc, camphor, and 
the root of the cimicifuga or black snake-root. 

Of these different remedies the one most employed in this city at pre- 
sent is, I think, the cimicifuga. This was first introduced into use by 
Dr. Jesse Young, and is now extensively employed and much relied 



TREATMENT. 477 

upon. Dr. Wood (Pract. of Med. vol. ii. p. 755) says: "I have in re- 
peated instances found it of itself adequate to the cure of the disease. " 
I have employed it myself only in four instances. In three of these, 
the children recovered entirely under its use, in one it failed to do any 
good, and recovery took place under the use of iron, the sea-bath, and 
in the course of time. One of the cases that recovered under its use 
was much the worst that I have ever met with. It was that of a 
boy of nine years, in whom the disease went so far as to destroy all 
power of locomotion. The child was unable to stand up even. At the 
same time the movements of the lips, cheeks, and tongue, were so vio- 
lent and irregular, and so little under the control of the will, that the 
power of speech was lost entirely for a period of four or five weeks. The 
choreatic spasm appeared to affect even the muscles of deglutition, so that 
the act of swallowing was often difficult and uncertain. Mastication also 
was impossible, and the child was unable to carry anything to his mouth, 
rendering it necessary to feed him, as one would a baby, with soft solids 
and fluids. During some two months, the muscles at the back of the 
neck became so weakened that the head could not be lifted from the pil- 
low or held erect, but fell from side to side or forwards like that of an 
infant. The condition of the child was altogether one of the most com- 
plete and distressing helplessness. During the first month of the case, 
it was treated with active cathartics, chiefly very large doses of cream of 
tartar and jalap, and with iron, but as the symptoms were constantly 
aggravating, the cathartics were abandoned except so far as to maintain 
by the occasional use of rhubarb and senna, a soluble state of the 
bowels, which were very much disposed to constipation. The patient 
was now put upon the use of decoction of cimicifuga, of which he began 
with four ounces, soon increased to half a pint per day, made in the pro- 
portion of half an ounce to the pint. The iron was continued. Under 
this treatment he very soon began to amend, and in two weeks showed a 
very decided improvement. Cod-liver oil was now added to the iron and 
cimicifuga, and in six weeks he was in great measure restored to health, 
and in the end recovered completely. 

The cimicifuga is given in powder, tincture, or decoction, and should 
be continued for several weeks in gradually increasing doses, until some 
visible effect is produced, as nausea, headache, vertigo or disordered 
vision. The usual doses are from half a drachm to a drachm of the 
powder, from one to two ounces of the officinal decoction, and one or two 
drachms of a saturated tincture, given three times a day. For my own 
part I prefer the decoction, of which I give to children of eight or nine 
years old, from four ounces to half a pint a day, made in the proportion 



478 CHOREA. 

of half an ounce of the root to a pint of boiling water. Prepared in this 
way, it is not a disagreeable drink, and is usually taken without much 
objection. 

The French authors recommend chiefly valerian, oxide of zinc, and 
assafcetida. Of these the one which has the highest reputation is vale- 
rian, and from the evidence adduced in its favor there can be no doubt 
that it exerts a very beneficial effect upon the disease. It may be given 
in the form of powder, infusion, or fluid extract. The dose of the powder 
is from twelve to eighteen grains in the day, to commence with, to be ra- 
pidly increased to several drachms, as the stomach becomes accustomed to 
it. It may be given in honey or preserve. I should prefer the fluid 
extract, of which half a teaspoonful may be given to a child eight or ten 
years old, three times a day, and the quantity gradually increased. The 
oil of valerian is employed by some practitioners. Oxide of zinc is given 
in doses of a grain every three hours to children eight years old, and is 
much relied upon by some practitioners. Assafcetida is recommended 
both by English and French writers. It is best given in pill, on account 
of the nauseous taste of the mixture. Two three-grain pills may be 
given to a child of four or six years of age, three times a day. Dr. 
Bardsley gave it by injection, in combination with laudanum, every eve- 
ning, after using musk and camphor through the day. 

Narcotics have been recommended by some writers. Those which are 
most employed are opium, belladonna, stramonium, and of late, strych- 
nia. Substances of this class are seldom, however, made the basis of 
treatment. Opium is useful in some cases in which the agitation is very 
great, so that the sleep of the child is much disturbed, but it is seldom 
necessary except as an adjuvant to other means ; and the remark applies 
equally to other remedies of the class. Within a few years M. Trous- 
seau has employed with success the sulphate of strychnia. 

Tonics. — Whenever the disease occurs in debilitated and anemic indi- 
viduals, remedies of this class prove of great efficacy. The ferruginous 
preparations are those most clearly indicated under the circumstances. 
Any of them may be selected. The best are the subcarbonate, Vallet's pills, 
and the pure metallic iron (Ferrum per hydrogen). Quinine is also 
recommended when the patient is feeble and weak. It may be given 
alone or in combination with iron. The citrate of iron and quinine would 
form a very good prescription under the circumstances mentioned. Cod- 
liver oil is an admirable remedy when the child is thin and weak, and 
especially when there is cause to suspect any tubercular predisposition. 

The cold plunge and shower bath have also been resorted to by a num- 
ber of practitioners, and there is evidence to show that they have often 
proved useful. The cases in which they are used should be selected, 



TREATMENT. 479 

however. They ought not to be employed unless followed by full re- 
action, nor unless the child is willing to take them. When the use of 
the bath terrifies or shocks the patient greatly, it cannot be proper. A 
warm or tepid bath used once a day, or every second day, would always 
be useful in promoting the general health, when the cold bath is not 
borne well. 

Sulphurous baths have been recommended and employed with much 
success, by M. Baudelocque of Paris. A rapid and definite cure was 
obtained in 58 out of 65 cases. Thirty drachms of sulphuret of potash 
are added to each bath, which is employed for at least one hour daily, at 
a temperature of 91°. Generally amelioration occurs after the second or 
third bath, but sometimes not until after twelve or fifteen days, a mean 
of twenty-two days having served for the cure of fifty out of fifty- seven 
cases. Where the case is retarded, it ordinarily depends upon the patient's 
powers being lowered by other remedies or insufficient diet, upon irritation 
of the skin induced by the bath, or upon acute irritation of the internal 
serous membranes ; circumstances contra-indicating the baths while they 
continue. The conjunction of other remedies retards rather than aids 
the case. Deducting the cases in which the bath was improperly used 
under the above circumstances, there remain but nine true failures in 
eighty-one cases, these being almost all recent or rheumatic choreas. 
(Dr. See, of Paris, on Chorea, Banking's Abstract, No. 16, p. 51.) 

A great variety of remedies besides those we have mentioned have been 
employed, and have more or less evidence in their favor. Amongst them 
are sulphate of zinc, nitrate of silver, subnitrate of bismuth, iodine, and 
a host of others which it is useless to enumerate. The sulphate of zinc 
has undoubtedly proved efficacious in some instances. About two grains 
may be given at first three times a day, and gradually increased to six or 
eight if the stomach bears the remedy well. 

Counter-irritation to the spine, in all its shapes, from pustulation with 
tartar emetic, issues, and blisters, down to frictions with coarse towels, 
have been proposed and employed in the treatment. The use of any but 
the milder remedies of this class is unnecessarily harsh and cruel, except 
when the disease is evidently dependent upon an affection of the brain or 
spinal marrow. The great majority of cases will recover perfectly well 
without a resort to such violent means, and they ought therefore to be 
avoided. 

Electricity has been resorted to, and apparently with good effects in 
some instances, and it might therefore be tried when other and simpler 
means fail, or in conjunction with these means. 

Gymnastic exercises have been recently employed with great success 
in the Children's Hospital at Paris. They were first employed under the 



480 CHOREA. 

guidance of M. Laisne, gymnastic professor at the Polytechnic School, 
their effects being tried first on scrofulous children. " Commencing with 
simple movement of the legs and arms, accompanied by appropriate songs, 
the children's progress was so rapid, that they were soon able to employ 
the orthopocdic ladder, the parallel bars, and other machinery, in succes- 
sion. By the twentieth lesson they were exercised in wrestling, and 
afterwards in running, special exercises being devised for the lame. From 
the first lesson the children became fired with emulation, and movements 
which seemed impossible were soon executed with ease and pleasure. A 
marked amelioration was speedily observed, their countenances becoming 
animated, their flesh firm, their voices stronger, their appetites keener 
and more regular ; glandular swellings which had long resisted all treat- 
ment, were resolved, and fistulous sores that had been open for years, 
closed up. The lessons, one hour each, were given three times a week ; 
and in the intervals the children amused themselves by repeating such of 
them as did not require machinery." This treatment, at first applied to 
scrofulous children, was, as stated above, extended to those laboring under 
nervous affections, partial paralysis, rickets, and especially chorea. Since 
1847, ninety-five children suffering from chorea, sometimes so obstinate 
as to have resisted the most various treatment, have been cured by this 
means alone, or in conjunction with other means, and no accident has 
resulted from the employment of the exercises. The movements are 
graduated according to the severity of the case, and they are repeated 
daily, but not for more than from fifteen to twenty-five minutes, so as not 
to induce fatigue or palpitation. " Improvement is sometimes seen after 
the first lesson, and at latest after the fifth or sixth ; so that at the end of 
a week we can judge whether the means are likely to prove efficacious, and 
if manifest improvement has not then taken place, it is doubtful whether 
the cure will be thus effected, or if it is, it will be so only after a long 
time. The worst as well as the slightest cases have reaped equal benefit, 
the cure in the favorable ones only requiring a mean of twenty-nine days, 
and old or relapsed chorea being more amenable than recent. Dr. See 
has found that when other remedies are conjoined with the gymnastics, 
the proportion of cures is less, and the period of their attainment later; 
and he recommends no other adjunct to be employed than good diet." 
(Dr. See on Chorea, Loc. Cit., No. 16, p. 50.) 

Hygienic Treatment. — The management of the hygiene of the 
patient is quite as important as any other part of the treatment. The 
diet should be arranged to suit the particular condition of the individual, 
and with a view to procure and maintain the most healthful possible state 
of the digestive apparatus. It should always be light and easily diges- 
tible, in order that neither the stomach nor bowels may be oppressed and 



CHOREA — TREATMENT. 481 

deranged by the products of an imperfect digestion. When the stomach 
is weak and dyspeptic, the food ought to consist for some days chiefly of 
preparations of milk and bread, whilst in the mean time, some tonic 
remedy is administered internally, in order to invigorate the power of 
that organ. As the digestive function becomes stronger, the child ought, 
as a general rule, to be put upon the kind of diet most likely to pro- 
mote the general health and vigor of body. It ought to consist of bread, 
milk, plain, wholesome meats, and simple vegetables. Coffee and tea, 
and all other nervous stimulants had better be avoided. The meats ought 
to be mutton, beef, chicken, or turkey. There are few vegetables, besides 
rice and potatoes, which are suitable under the circumstances. All can- 
dies, preserves, unripe, coarse, or dried fruit, hot bread, and cakes, except 
the very simplest, ought to be withheld. 

Of dress I need merely say that it must be suited to the season. Ex- 
ercise, or at least, exposure to fresh air and insolation, are of the utmost 
consequence. When the disease is so violent as to prevent the child 
from walking, it ought to be taken to ride as often as possible. In cases 
which seem connected with a debilitated and ancemic condition of the 
constitution, removal to the country, and particularly to the seaside, will 
often effect a cure with great rapidity. Whenever, indeed, a patient 
inhabiting a large city or town can be conveniently taken to the seaside 
in the summer, it ought to be done, for the change is useful not only at 
the time, but it lessens, also, by strengthening and invigorating the con- 
stitution for the future, the danger of a relapse. 



31 



CLASS IV. 
ERUPTIVE FEVERS. 

ARTICLE I. 

SCARLET FEVER OR SCARLATINA. 

Definition; Frequency; Forms. — Scarlet fever is an epidemic and 
contagious exantheme, characterized by continued fever ; by a scarlet rash, 
which appears on the first or second day of the disease, ends usually about 
the sixth or seventh, and in rare cases as late as the tenth, and is fol- 
lowed by desquamation ; and by simultaneous inflammation of the tonsils, 
and of the mucous membrane of the mouth and pharynx. 

The frequency of the disease is exceedingly variable in different years, 
because of its epidemic nature. I find by reference to the tables of mor- 
tality of this city, published by Dr. Gr. Emerson (Am. Journ. Med. 
Sciences, vol. i. 1827), that in the twenty years from 1807 to 1827, there 
were 93 deaths from the disease under twenty years of age. In thirteen 
of these years, from 1 to 8 deaths occurred per annum ; in five successive 
years, 1812 to 1817, not a single death is reported, while in the two 
remaining years, 1820 and 1821, the deaths were 30 in the former, and 
13 in the latter. In another communication in the same Journal (No- 
vember, 1831), Dr. E. gives the mortality from the disease under twenty 
years of age, during the four years from 1827 to 1830, inclusive. In 
1827 there was one death; in 1828 none; in 1829 nine; and in 1830 
forty. During the five years from 1844 to 1848, inclusive, there occurred 
in this city 1175 deaths from the disease under consideration; of these 
262 were in 1844, 191 in 1845, 216 in 1846, 339 in 1847, and 167 in 
1848. 

It is, I believe, a decidedly less frequent disease on the whole than 
measles, though when short periods of time are taken, the deaths from 
scarlatina sometimes preponderate. Gruersant and Blache (Diet, de Med. 
t. 28, p. 173), state that it is less frequent than measles or variola. 
They added together the cases of eruptive fevers collected in 1838 and 
1839, by Roger, Rilliet and Barthez, and Barrier, in the Children's Hos- 
pital at Paris, and found that there had been only 157 cases of scarlet 



SCARLET FEVER — FORMS. 483 

fever, whilst there were 267 of measles, and 213 of variola and varioloid. 
It appears from Dr. Emerson's paper that in the period of twenty years 
referred to, there were only 93 deaths from scarlet fever, whilst there 
were 654 from measles, under twenty years of age. 

To show how uncertain the proportion is, however, I will state the fact 
that in the five years from 1844 to 1848, inclusive, 1175 deaths occurred 
in this city from scarlet fever, while, during the same period, only 311 
were caused by measles. 

The forms of the disease generally enumerated are the simple, anginose, 
and malignant. Authors differ widely in their descriptions of these three 
forms. Thus most of the English authors include in the simple form only 
the cases in which there is no affection of the fauces, while the anginose 
form includes all in which there is any throat-affection whatever. Rayer, 
on the contrary, describes under the head of the simple form the cases in 
which the throat-affection is mild, while he considers the anginose form 
to be that in which a pseudo-membranous angina occurs. Again, the 
descriptions of the malignant form are vague and uncertain, some in- 
cluding under this term only the rapidly fatal cases in which cerebral 
symptoms are present, while others include those also which are rendered 
malignant by the occurrence of pseudo-membranous angina. 

I believe this division of scarlet fever into distinct forms and varieties 
to be, for several reasons, a faulty and imperfect arrangement. It is not, 
it appears to me, in the first place, consonant with the nature of the 
disease. Scarlet fever is, in fact, with all its degrees of severity, and 
apparent differences, a single and distinct fever, produced by one cause, 
determining similar effects, howsoever much they may vary in degree, and 
requiring no more than does typhoid fever to be broken up into the 
variety of different forms, which it has been customary to ascribe to it. 
Again, the above mode of division is not, I am sure, a good one for prac- 
tical purposes. It is impossible, indeed, as I have often found it, to 
refer many cases we meet with in practice, clearly and satisfactorily to 
any one of the forms of the disease described in books. The simple form 
of the English writers, or that in which there is no anginose affection 
whatever, does not exist at all in my opinion. I believe that inflammation 
of the mucous membrane of the fauces constitutes an essential element of 
the disease ; for I have never yet seen a case of scarlatina in which it was 
not present to a greater or less extent. It is often very slight, so slight, 
indeed, as to be unaccompanied by any evidence of pain in the part, but 
in all that I have examined, it has been decided and palpable. This sup- 
posed form of the disease does not, therefore, in my opinion, exist. 

The two other forms usually described, the anginose and malignant, are 
also of little use practically, since I have found that in all severe or grave 



484 SCARLET FEVER. 

cases, in which the patient did not die under the first shock of the scar- 
latinous poison, there has been developed a violent and dangerous anginose 
inflammation about the third or fourth day ; so that it is fair to say that I 
cannot imagine any malignant case, lasting over the third or fourth day, 
which is not anginose, nor any severe anginose case, which might not also 
be styled, from its dangerous character, malignant. I have, in fact, found 
it impossible, in my experience, to draw the distinction clearly and indubi- 
tably between the anginose and malignant varieties, because all severe 
cases partake more or less of the features of both. 

Feeling this difficulty of describing the disease according to the mode 
that has hitherto been generally followed, and believing it also to be in- 
sufficient for practical purposes, I was led to attempt, in the first edition 
of this work, a different arrangement. 

I made, accordingly, two forms or degrees of the disease, which I desig- 
nated by the terms regular and grave. In the first form or degree I 
included all the cases in which the angina was simple and the eruption 
regular in all respects ; in which there was no predominance of one set 
of symptoms over another, but in which all held a due relation to each 
other. In this form was embraced all the cases of scarlatina simplex of 
writers, and many of those of scarlatina anginosa of the English authors. 
In the second form I included the cases which departed from the regular 
course of the disease, and which were rendered dangerous by the occur- 
rence of severe symptoms not belonging in the same degree to the simple 
affection. This form I subdivided into two varieties, the grave anginose, 
which contained all the cases accompanied by pseudo-membranous, ulce- 
rative, or gangrenous angina; and the grave cerebral, which comprised all 
those marked by the early occurrence of dangerous cerebral symptoms. 
The grave form comprehended, therefore, some of the cases of scarlatina 
anginosa, and all those of scarlatina maligna of writers, dividing, however, 
those in which a pseudo-membranous, ulcerative, or gangrenous angina, 
determined the type of the attack, from those in which the cerebral or 
nervous symptoms gave to the case its stamp. 

More extended observation and more patient reflection have taught me 
that this division also is incorrect, — that it does not afford a good classi- 
fication for the purposes of description, and that it is defective as a guide 
in practice. 

I have determined, therefore, to adopt, in the present edition, a different 
method of considering the disease, one which I believe to be more con- 
sistent with its nature, more suitable for the purposes of description, and 
much more likely to prove useful in practice. I shall follow the same 
arrangement in regard to scarlet fever as that now generally employed for 
typhoid fever. I shall consider it as a single and distinct disease, and not 



causes. 485 

as made up of a number of uncertain and imperfectly separated forms or 
varieties, all of which so run into each other, as to make it absolutely 
impossible to draw the line clearly and palpably between them. The only 
division I shall make will be into mild and grave cases, since the only 
real difference between the cases is a difference in the degree of severity 
they exhibit. 

Causes. — It has been abundantly proved by long and reiterated obser- 
vation that scarlatina is propagated by two causes, contagion, and epidemic 
influence. Of these two modes of propagation, I have not the least doubt 
myself that the latter is by far the most active. It is only necessary to 
look over the results afforded by the tables of mortality for this city, as 
quoted in the early part of this article, and to observe that in some years 
the disease caused a heavy mortality, in others a very small one, and that 
in others again not a single death from it is reported, to be convinced that 
it is of a highly epidemic nature. 

The contagious character of scarlatina has been doubted by some few per- 
sons, but seems to me clearly proved by the evidence adduced by various 
writers. My own experience also convinces me that it is a contagious disease, 
though much less so, I am sure, than either small-pox, measles, hooping- 
cough, or chicken-pox. I have quite frequently indeed, known children 
exposed directly and for a considerable length of time to the infection, to 
escape entirely, while it is extremely rare for me to meet with children, 
unprotected by previous attacks, who can resist the contagion of measles, 
hooping-cough, or varicella. But, though I believe it to be much less 
highly contagious than has been generally supposed, and than the other 
contagious diseases just named, I am also well convinced, as was stated 
above, that it is propagated to a considerable extent by a direct contagion. 
I have in a number of instances, known one child in a family to contract 
the disease from direct exposure to it, or from the epidemic constitution 
of the atmosphere, and a second, third, and even a fourth, to take the dis- 
ease from the first, in five, seven, or nine days after the latter had fallen 
sick. In other instances, on the contrary, it would seem that either seve- 
ral children in one family contract the disease nearly simultaneously from 
the epidemic influence, or else that the period of incubation is sometimes 
very short. For example, during the winter season, a child five months old, 
who had never been out of the house, was seized with it. On the second 
day after the eruption appeared on this child, her sister, between four 
and five years old, fell sick, and on the third day another sister, the only 
remaining child, between two and three years of age. In the first of 
these cases it must have been contracted through the epidemic influence 
which was at that time prevalent in the city, since the child had in no 
way been directly exposed to it. In the other two, we must either sup- 



4S6 



SCARLET FEVER. 



pose the cause to have been the same, or else that the period of incuba- 
tion was only two and three days in the respective cases. 

The period of incubation is shorter than in other contagious eruptive 
diseases. It may be stated to vary between two or three days, and two or 
three weeks. MM. Guersant and Blache are of opinion that in the majo- 
rity of cases, it is from three to seven days. MM. Rilliet and Barthez 
found that of 38 cases in which the time was recorded, it was between 2 
and 7 days in 1G, between 8 and 13 in 15, and 15 and 40 in 8 cases. 
My own observation would fix it at 9 or 15 days in the majority of cases. 

It is impossible to state with any certainty the length of time during 
which the power of imparting the contagion continues in the patient. 
Cazenave (Abrege Prat, des Mai. de la Peau, p. 54), states that it lasts 
throughout the period of desquamation, and that it would even seem to 
be most active at that time. 

The epidemics of scarlet fever vary exceedingly in their extent and 
violence. During the years 1841 and 1842, the disease prevailed very 
extensively in this city, and assumed a malignant type, so that in a con- 
siderable number of families, two, three, and even four children, died within 
a very short period. 

The disease prevails at all seasons, but is most frequent in the spring 
and summer, and next in the autumn. It rarely occurs more than once 
in the same individual, but that it does so sometimes is proved by facts 
brought forward by different authors. 

It has been asserted, indeed, that second attacks of scarlet fever occur 
in the same person not more than once in a thousand cases. Of the truth 
of this assertion I am, however, very doubtful, since it has occurred to me 
to see no less than three examples of second attacks in my own short ex- 
perience. I attended in this city one child with perfectly well-marked 
scarlet fever, attested by subsequent anasarca, who had had the disease 
two years previously under the care of my father Prof. C. D. Meigs. 
This winter (1852) I attended two children in one family with the dis- 
ease, one of whom died, and both of whom had had the disease four years 
and a half before. They were attended in the first attack by myself, and 
as it chanced, owing to my absence from town during one day, they were 
seen also by one of my friends who made no exception whatever to the 
diagnosis of scarlet fever. The only doubt as to these cases having been 
veritable examples of double attacks of the disease, must rest of course 
upon the diagnosis. In the first example the diagnosis was made by my 
father in the first attack, and by myself in the second. In the two 
latter it was made by myself in both, accidentally confirmed in the first 
attack in both children, by the opinion of a competent professional friend. 
The first attacks in the latter cases were both mild, but well marked ) 



CAUSES — SYMPTOMS. 487 

the second attacks were both severe, and one proved fatal on the 
sixth day. I have not the least doubt myself that all of the three were 
cases of true scarlet fever. If they were not, the two latter must have 
been cases of roseola, so closely resembling scarlatina as to oblige me to 
confess myself incompetent to distinguish between the two diseases. 
What adds to the certainty that the two which came under my own ob- 
servation were true cases of scarlet fever, is the fact they occurred simul- 
taneously with a third case in the same family. Now, roseola is not apt, 
so far as I know, to occur epidemically in a household. Nearly all the 
cases of that disease, that I have seen, have been solitary ones. 

Age. — MM. Rilliet and Barthez state that it is most common from six 
to ten years of age. Of 173 cases that I have seen, in which the age was 
noted, 50 occurred under 3 years of age, 51 between 3 and 5 years, 33 
between 5 and 7, 32 between 7 and 10, and 7 between 10 and 15. From 
this it would appear to be more common in the first five years than between 
the ages of five and ten, since of the 173 cases, 101 occurred in the former, 
and only 65 in the latter period. By uniting the statistical tables of Dr. 
Emerson with those of Dr. Condie {Dk. of Quid. 2d ed., note, p. 86), I 
obtain the deaths from scarlatina in this city at different ages for a period 
of thirty years. Their tables show clearly that the disease is most com- 
mon between the ages of one and five years. The total mortality under 
ten years, during the time stated, was 2171, of which 132 were under one 
year of age, 411 between one and two, 1130 between two and five, and 
510 between five and ten. 

The earliest age at which I have seen it perfectly well marked, was 
twenty-one days. I saw it once also in a child five months of age. It is 
not nearly so common in the first year of life as it is afterwards. The 
largest number of cases occur, according to my experience, in the second, 
third, and fourth years of life. 

The influence of sex seems not to have been determined with certainty. 
Dr. Tweedie ( Cyclop, of Pract. Med., Art. Scarlatina) says it is most 
common in girls. MM. Rilliet and Barthez, on the contrary, state it to 
be more common in boys. Of 184 cases under 15 years of age that I 
have seen, in which the sex was noted, 90 occurred in males, and 94 in 
females. The truth is probably that under puberty it attacks the two 
sexes with about equal frequency, while after that age it is most common 
in females. 

Symptoms; Course; Duration. — As has already been stated, I intend, 
in my description of the symptoms of scarlet fever, to depart from the 
ordinary mode of arrangement of the subject. I shall discard the old 
division of the disease into three forms or degrees, scarlatina simplex, 
anginosa, and maligna, and substitute, for reasons already given, the 



488 SCARLET FEVER. 



sail 



simple division into mild and grave cases. I shall class as mild cases 
those which pursue an even and regular course, without being accompanied 
by dangerous or malignant symptoms, in which there occur neither vio- 
lent nervous, nor threatening anginose symptoms; while among the 
grave cases I shall place all those in which there occur severe nervous 
symptoms, in the form of violent delirium, coma, or convulsions, dan- 
gerous symptoms in the form of diphtheritic, ulcerative, or gangrenous 
inflammation of the mucous membrane of the fauces, and, finally, those 
in which the general symptoms assume a low and typhous character. 
When it seems convenient, I shall follow the usual division of the course 
of the disease into the three stages of invasion, eruption, and desquama- 
tion. 

Mild cases. — Stage of Invasion. — The following description of the 
symptoms of scarlet fever in its mild form is drawn partly from books, 
but much more from my own observation of 144 mild cases of the dis- 
ease, of all of which I have kept a faithful record, and when there was 
anything peculiar or important, full notes. 

The onset of mild cases of scarlet fever is generally sudden. A child 
is well, or so slightly ailing, on one day, as that the change from its usual 
condition is not noticed at the time, though it may be recollected after- 
wards, and on the following day, or often within twelve hours or even 
less, the symptoms of the disease become marked and characteristic. In 
a large majority of the cases that I have seen, the eruption is already out 
at my first visit. Frequently the patient has been put to bed well in the 
evening, and, becoming restless and feverish in the night, is found on the 
following morning with fever, sore throat, and very considerable eruption ; 
or, as happened in one of my cases, a child gets up in the morning appa- 
rently well, breakfasts as usual, goes to church, and falling sick while 
there, comes home and a few hours later shows the eruption over the 
neck and upper part of the trijnk, and has fever and sore throat. In 
another case, a boy between seven and eight years old was perfectly well 
in the morning. At 2 p. M., his mother, a most sensible and accurate 
person, observed him playing in the garden, and remarked upon his 
healthy looks. Fifteen minutes after this he felt sick at his stomach ; 
he came into the house and went up to the nursery, looking pale and 
pinched, with a cold skin, and nearly fainted in the nurse's arms. 
He had then in the course of an hour three copious and watery stools, 
each one accompanied with vomiting. I saw him one hour after this, 
dozing, very pale, with pinched features, sunken and half-closed eyes, 
cool surface, and with the pulse at 128, and rather feeble. There was 
no eruption. At 6 P. M. I found him with a hot and dry skin, with the 



SYMPTOMS OF MILD CASES. 489 

tongue heavily coated, the fauces swollen and showing flecks of exuda- 
tion upon the tonsils, a pulse at 128, and with a well-marked scarlatinous 
eruption coming out abundantly. The case pursued a very regular course, 
without dangerous or malignant symptoms of any kind. 

But the invasion, though sudden in nearly all cases, is not always as 
precipitate as I have just described. When we come to analyze the early 
symptoms we find that the first one observed in most of the cases is fever, 
marked by considerable acceleration of the pulse and heat of skin. In 
some few cases the fever is preceded by the ordinary prodromes of febrile 
diseases, languor, lassitude, pains in the back and limbs, and slight 
rigors. Simultaneously with the fever, there is, in nearly all cases, more 
or less soreness of the throat. In all that I have examined, even those 
in which no pain was complained of, there has been redness, or redness 
with swelling, of the fauces. In a majority of the cases vomiting occurs, 
or if not vomiting, some degree of nausea. There is complete anorexia; 
the thirst is acute ; the bowels are usually in their natural condition, or 
slightly constipated. The child is quiet and dull, or else restless and 
irritable, and sometimes there is delirium ; the face is generally flushed, 
and the eyes often slightly injected. The duration of these symptoms is 
irregular. They are said to last generally about a day, but they may 
continue either a shorter or longer period. I am very sure, from my own 
observation, as I have already, indeed, stated, that these preparatory 
symptoms rarely precede the eruption more than twelve hours, and very 
often the time is even less. 

Stage of Eruption. — The eruption generally appears first on the face 
and neck, whence it extends rapidly over the whole surface. It continues 
to increase in extent and intensity, so as to reach its maximum about the 
third or fourth day. It appears first in minute dark-red points dotted 
upon a rose-colored surface, forming patches of irregular shape, of 
considerable size, level with the skin, disappearing under pressure, divided 
at first by portions of healthy skin, but running rapidly together, and 
giving to large portions of the surface a uniform scarlet color. The 
eruption is not generally equally diffused over the whole body, but is 
more marked upon one portion than another. It is often most intense on 
the back, and is there of a deeper color than elsewhere, and not unfre- 
quently assumes a purple hue. It is generally very well marked on the 
abbdomen and thighs, and about the articulations, and assumes in those 
regions a particularly bright tint. 

It does not always cover the whole surface, but in some very mild 
cases, and, as we shall find when treating of the grave cases, in these 
latter, also, it may occur only in patches of moderate extent upon diffe- 



490 SCARLET FEVER. 






rent portions of the body, leaving us at times in some doubt as to the 
real nature of the rash. 

The surface of the eruption is smooth and even to the touch, unless, as 
not uufrequently happens, it is accompanied by the development of miliary 
vesicles, or crops of minute pimples, or pustules. A certain degree of 
roughness is sometimes occasioned also by enlargement of the papillae of 
the skin in various parts of the body, particularly on the extensor surfaces 
of the limbs; but these are evidently independent of the characteristic 
eruption. The skin upon some parts of the body, especially the face, 
hands, and feet, often presents a swollen appearance, rendering the move- 
ments somewhat stiff. There is in most cases a feeling of burning, irri- 
tation, and itching in the skin, the latter of which symptoms increases as 
the malady progresses. 

The eruption generally reaches its height about the fourth day, and 
then remains stationary for one, or less frequently two days, after which 
it begins to decline. Its decline is marked by a diminution in the inten- 
sity of the color, which, from scarlet becomes red, then rose-colored, and 
growing paler and paler, finally disappears entirely about the sixth, 
seventh, or eighth day. In some very mild cases, however, the whole 
duration of the eruption is not over two or three days, and in such the 
color it imparts to the skin is never very bright nor very deep, nor is it 
accompanied by intense heat, or by much irritation or itching. 

The symptoms which preceded the eruption do not subside on its ap- 
pearance, but persist or are augmented. The febrile movement continues 
unabated ; the pulse is full, strong, and frequent, running up very soon 
after the onset to 120, 140, 150, and often to 160. This frequency of 
the pulse is, in fact, one of the most marked symptoms of the disease. I 
have rarely, even in very mild cases, found it less than 120, and in not 
a few it has been in the first few days, and in children of four or six 
years old even, as high as 168 or 170. Occasionally, however, it has 
been lower, and in one case that occurred to me lately, in a boy five years 
old, it was 96 on the second day, and only 88 on the third, though there 
was still a good deal of rash upon the skin. The skin is burning hot and 
dry, as a general rule, and loses its softness and suppleness. The expres- 
sion of the face is usually natural. The eye is often animated, and slightly 
injected. The respiration is generally easy and natural, though sometimes 
when the fever is violent, it becomes quickened. The auscultation and 
percussion are natural, unless some complication exists. There is often 
a rather frequent cough, which is dry, and evidently depends on the 
guttural inflammation, and not on any bronchial or pulmonary affection ; 
it exists during the early period of the eruption, and declines with the 
inflammation of the fauces. The voice is seldom altered beyond having 



SYMPTOMS OF MILD CASES. 491 

a nasal sound, so long as the disease continues simple and regular. If the 
voice become hoarse or whispering, it indicates an extension of inflammation 
from the pharynx to the larynx. The anorexia continues until the erup- 
tion begins to decline, and the thirst is acute up to the same period, when 
it moderates. At first the dorsum of the tongue is covered with a whitish 
or yellowish-white fur of variable thickness, while its tip and edges are of 
a deep red color. After two or three days, and during the course of the 
eruption, the coating just described disappears from the tongue, and its 
whole surface assumes a deep red tint and a shining appearance, which 
makes it look like raw flesh. At the same time it is often much dimi- 
nished in size from contraction of its tissues, and its papillae become 
enlarged and projecting; this condition generally lasts from six to ten 
days, after which the tongue returns to its natural state ; it is com- 
monly moist throughout the attack. Vomiting is rarely troublesome 
in mild cases, though it often occurs ; the bowels continue nearly in 
their natural condition ; in some few cases slight diarrhoea occurs, but 
more frequently there is very moderate constipation which requires the 
use of mild laxatives. The abdomen is natural in most of the cases : 
sometimes, however, there is slight tension and pain for a few days, 
which coincide generally with enlargement of the liver, or more rarely of 
the spleen. The urinary secretion is usually more or less reddened as in 
other febrile diseases. 

Early in the second, or even in the first stage, the fauces present the signs 
of inflammatory action : the pharynx is reddened, and in some instances 
swelled ; the tonsils enlarge and become red ; the submaxillary and lym- 
phatic glands are somewhat tumefied, and tender to the touch, and when 
the case is at all severe, deglutition is generally painful, and in some 
instances extremely so. The absence of complaints of sore throat in a 
child, or the fact of its swallowing without hesitation or apparent diffi- 
culty, is no proof that angina does not exist, as I have always found upon 
examination in a good light much greater redness than natural, and in 
many instances redness and swelling combined. As the eruption pro- 
gresses, and the tongue loses its coat and becomes red, the inflammation 
of the pharynx usually augments ; the redness becomes deeper, and the 
tonsils are more swelled and painful, and dotted over with small white 
spots, or with thin, whitish, and soft false membranes. The throat-affec- 
tion, however, is rarely severe enough to constitute a serious danger in 
mild scarlatina, while in many of the malignant cases, it is a fre- 
quent cause of a fatal termination. During the eruption, the nostrils 
are either dry and incrusted, or there is some coryza. The strength of 
the child is reduced for the time, but there - are no signs of prostration, 
and the decubitus is indifferent. There is almost always more or less dis- 



492 SCARLET FEVER. 

order of the nervous system, sometimes amounting only to headache and 
restlessness, while in other instances there is great irritability, wakeful- 
ness, and occasionally delirium, especially at night. 

Stage of Decline and Desquamation. — The eruption reaches its height, 
as already stated, about the third or fourth day, then remains stationary 
for one or two days, and afterwards declines gradually, so that no traces 
are left on the sixth, usually, or at most in rare cases, on the ninth or 
tenth day. In some very mild attacks, the whole duration of the eruption 
is not over two or three days. By the third day it has disappeared entirely. 
Such cases are not, however, very common. The other symptoms, both 
general and local, decline with the eruption ; the pulse loses its frequency, 
and falls to the natural standard ; the heat of the surface first subsides 
and then disappears, but the skin remains somewhat harsh ; the redness 
and swelling of the tonsils and pharynx diminish; the spots of false 
membrane are absorbed or thrown off; the deglutition becomes easy if it 
have been difficult, and soon all signs of throat-affection vanish; the 
tongue cleans off, becomes reddish and glossy, and after a time returns 
to its natural state. 

At the time that the subsidence of all the symptoms takes place, de- 
squamation begins. It dates therefore in most cases from about the sixth 
day, though it may be either earlier or later. It commences in most of 
the cases on the face and neck, though in a few instances it appears first 
on the abdomen. It then extends gradually over the body and becomes 
general. About the thorax and abdomen it occurs in the form of minute 
points, like those which result from the desiccation of sudamina ; on the 
face it is in the form of thin light scales or squamae, while on the extre- 
mities large flakes of the epidermis become separated from the derm, and 
are removed by the child, or rubbed off by his movements in bed; these 
flakes are sometimes so large on the hands and feet as to form complete 
moulds of the fingers and toes, or even of the hands and feet. The whole 
process usually occupies some ten or twelve days, but may be prolonged 
even into the third week. It is generally accompanied by roughness and 
dryness, and some itching and irritation of the skin. Not unfrequently, 
the surface beneath the exfoliation is left tender and irritable for some 
time afterwards. 

Grave cases. — The following description of the symptoms of grave cases 
of scarlet fever is, like that which has just been given of the mild cases, 
drawn partly from books, and partly from my own observation of the dis- 
ease. My own experience includes the careful observation, and a more 
or less full notation, of 41 grave cases. I shall include under this division 
of the subject, as already stated, most of the cases usually classed by 



SYMPTOMS OP GRAVE CASES. 493 

writers under the title of scarlatina anginosa, and all those generally de- 
scribed under the title of scarlatina maligna. 

The symptoms which mark the invasion of grave cases of scarlet fever, 
though sufficiently alike in all to show the unity of the disease, differ very 
materially as to their degree of severity in different cases. In one set 
(rather less than a third, or 13 in 41, of my cases), they are most violent 
and dangerous, or, indeed, appalling in their character. From the first, 
they declare the imminent danger of the attack. In the second set (rather 
more than two-thirds, or 28 in 41, of my cases), they may be either evi- 
dently severe and dangerous, though not appalling as in the first, or they 
may be much milder, more like those which mark the invasion of mild 
cases, but even under these circumstances they soon put on their grave 
and dangerous character. 

The first set of cases, or those in which the symptoms are the most 
severe of all, usually begin with nervous symptoms. The onset is in some 
instantaneous. In one, the little patient, a girl two years old, whose bro- 
ther and sister had been sick for some days with scarlatina, was put to 
bed in the evening in her usual health, which was strong and vigorous. 
She slept quietly through the night, but was found by the mother the next 
morning in a state of drowsiness, violent fever, and covered with a deep- 
red scarlatinous rash. She soon became comatose, and died on the third 
day. In another case, a boy eleven months old was a little fretful in the 
afternoon, but was put to bed in the evening as usual and went to sleep. 
About ten o'clock the nurse heard a rustling in the bed, and on going to 
it, found him in a violent general convulsion. The next morning he was 
covered with a scarlet rash, which became deeper and deeper as the dis- 
ease went on. On the second day he was nearly insensible, and had fre- 
quent attacks of convulsions ; on the third day he had retraction of the 
neck, with spasmodic twitchings, and at the end of that day, died in a 
state of coma. In a third case, a boy six years old, whose sister had been 
sick for a week with a mild attack, went to bed well. At three o'clock 
in the morning, he was seized with vomiting and purging, paleness and 
coolness of the skin, and great exhaustion. At nine o'clock he was drowsy 
and dull, the skin was pale and cool, and the pulse extremely rapid ; the 
vomiting and purging had ceased ) at 12 M. he was comatose and had a 
convulsion. From this time he continued comatose until he died at 6 P. M. 
of the same day, after an illness of fifteen hours. In a fourth instance, the 
invasion was that of croup ; after a few hours came on coma and convul- 
sions ) patches of eruption then appeared on the trunk, and death occurred 
in twenty-four hours from the beginning. The subject of this case, 
a boy five years old, was thought to be so well in the afternoon of the day 
he was taken sick, that he had been sent out on a visit to a relation, and 



494 SCARLET FEVER. 

while there fell sick. In the fifth case the onset was sudden, with violent 
fever, drowsiness, deep suffusion of the skin, and in a few hours insensi- 
bility, then general convulsions, and death in thirty-six hours. In a sixth, 
in a boy four years old, the attack came on with vomiting, paleness, drowsi- 
ness, and then a scarlet rash ; after a few days, coryza and otorrhcea occurred ; 
the tongue and lips became cracked and dry; in the second week, the 
child was comatose, with occasional attacks of extreme jactitation, and the 
most violent hydrocephalic cries, which condition lasted ten days. After 
this there was diarrhoea, extreme emaciation, loss of speech, and entire 
deafness. Gradually, however, the fever disappeared, the tongue cleaned 
off, and intelligence very slowly returned ; in the sixth week convalescence 
was firmly established, and the child recovered perfectly with the excep- 
tion of his hearing, which remained very dull in consequence of the per- 
foration of both membranse tympanorum. In a seventh, a girl eight years 
old, whose brother was then sick in the house with the disease, was in the 
morning well. At breakfast she said she felt sick and soon went to bed. 
At 5 P. M. of that day, she was attacked with a general convulsion which 
lasted about fifteen minutes. The pulse, immediately after the convulsion 
was 150. At 11 P. M. she had another convulsion. Through that night, 
she was very restless and wandering. On the morning of the second day, 
there was a third convulsion, which, however, was very short. The pulse 
was now 160, small, and feeble. The patient was very heavy and dull, an- 
swering questions slowly, and with great difficulty, and during part of the 
day she was comatose. On the third day, she was better, the pulse having 
fallen to 152, and she was less dull, though she still continued very heavy 
and inattentive unless aroused by persevering efforts. The limbs were 
cool, while the head and trunk were hot. The eruption was thick on the 
trunk and upper part of the extremities ; elsewhere it was scanty. Wher- 
ever it existed, it was of a deep red or purplish color, and the capillary cir- 
culation was sluggish and imperfect. On the fourth day, her intellectual 
condition continued better, but the extremities were still cold, and the lym- 
phatic glands and subcutaneous tissues about the lower jaw and neck had 
begun to swell. On the fifth day, the swelling had become very great; the 
stupor had returned ; a profuse and disgusting coryza and otorrhoea had 
set in ; and the edges of the eyelids were inflamed and sore. On the sixth 
day, the discharges from the mucous membranes of the head were very 
copious, and consisted of a thick, offensive purulent fluid, intermixed 
with dull whitish grumous particles. The patient was now comatose or 
very restless ; she swallowed with great difficulty ; the swelling about the 
lower jaw, and under the throat was enormous; the pulse was rapid and 
small ; the eruption was very dark in tint ; the cutaneous circulation was 
slow ; the extremities were cold, and death occurred about the mid- 



SYMPTOMS OP GRAVE CASES. 495 

die of this day. In another case, the subject of which was a girl between 
three and four years old, the attack began with severe inflammation of the 
throat, causing great difficulty in swallowing. The rash on the first day 
was very extensive and of a deep red color. The child was drowsy and 
heavy, or else delirious. On the second day, she was comatose, and had 
strabismus and automatic movements of the limbs. On the third day the 
coma continued, and there were automatic movements of the extensor 
muscles, with retraction of the head. The eruption continued vivid, but 
was of a dark red color. Death occurred in the middle of the fourth day, 
in a state of coma, without convulsions. In still another case, a boy, be- 
tween eight and nine years old, was attacked suddenly, while in good 
health, with vomiting, sore throat, and high fever. Twelve hours after 
the onset, he had a severe convulsion, which lasted fifteen minutes. 
He soon recovered from this, however, and remained perfectly intelligent. 
On the second day the rash was moderate ; there was violent fever, and 
the child was heavy, but, when roused, still intelligent. Early in this 
day, a severe fit occurred. This was most violent, as severe as the worst 
epileptic convulsion. It lasted one hour and three-quarters. The pulse, 
after this, was 145. On the third and fourth days, the symptoms im- 
proved very much, the pulse having fallen to 125 and 132, but he con- 
tinued drowsy and heavy. The eruption came out most abundantly. 
The fauces were very much inflamed and somewhat ulcerated, and the 
external lymphatic glands were enlarged, but still the swallowing was not 
difficult. On the fifth day he was not so well, being more restless and 
heavy alternately. There had now come on much difficulty in breathing, 
and some croupal sound. The latter symptom increased through the day, 
until the dyspnoea became very great. Deglutition now became exces- 
sively difficult; the external swelling increased; attacks of suffocation at- 
tended with the most painful and distressing jactitation came on, and 
were renewed more and more frequently; and death occurred by asphyxia 
about the middle of the sixth day. In a tenth case, in a girl five months 
old, convulsions occurred on the second day. These were followed by coma 
lasting several days, and by enormous swelling of the lymphatic glands and 
subcutaneous tissues on the left side of the neck, and by a less degree of 
swelling on the right side of the neck. The glands of both sides suppu- 
rated and were opened, and the child finally recovered perfectly. In an 
eleventh case, in a boy seven years old, an attack of general convulsions 
took place on the third day, after which there were delirium and coma 
alternately for several days, with coryza, angina, and offensive otorrhoea, 
lasting in all six weeks. The child recovered, but remained deaf. 

In this form of the disease, therefore, the symptoms are of the most 
virulent character. The onset is sudden. The child passes within a few 



496 SCARLET FEVER. 

hours from a state of apparent health, into one of the extremest danger. 
Most of the cases begin with violent fever, and great depression of the 
strength. The pulse soon becomes very rapid (140, 150, 180), or so quick 
that it cannot be counted, and it is at the same time small and often ir- 
regular. The skin is dry and burning hot in some parts, in others cool 
or even cold. There is generally nausea or vomiting, and these may be 
violent and constant. These are accompanied in some cases, but, in my 
experience, only in the severest of all, by colliquative diarrhoea and me- 
teorism. Delirium often exists from the first, or else there is drowsiness 
and dulness of intelligence, verging gradually into coma. In the most 
violent cases, the stupor or coma alternate with convulsions, which may 
cause a fatal termination in eighteen, twenty-four, or thirty-six hours. 

When a case of this kind lasts over three, or even two days, the violence 
of the nervous symptoms almost always subsides ; the convulsions cease 
to recur ; the delirium is less violent ; the coma gives way to drowsiness, 
or the patient becomes again quite intelligent and observant ; the pulse 
often falls in frequency, and the heat of skin may diminish, and the 
eruption assume a more favorable appearance. All the symptoms seem, 
indeed, to be more promising, and very often both the physician and 
friends are elated with the apparent improvement in the patient's con- 
dition. Nor are these hopes always illusory, since children do recover 
occasionally even in cases that have exhibited the most threatening and 
malignant appearance at the moment of invasion. It happens, unfortu- 
nately, however, in a majority of such attacks, that the improvement 
which takes place on the third or fourth day is only momentary. The 
nervous symptoms subside, but new ones make their appearance in the 
shape of severe inflammation, membranous deposit upon, or ulceration of 
the fauces, and of extensive swelling and induration of the lymphatic 
glands and subcutaneous tissues about the angles of the inferior jaw, and 
under the chin and throat. In connexion with the throat-affection which 
developes itself in this way, it is very common to have abundant purulent 
coryza, and often also otorrhoea. The symptoms assume, in fact, the 
features of the cases usually described under the title of scarlatina 
anginosa. As I shall, however, describe them directly in my account of 
the second set of grave cases, it is unnecessary to pursue the description 
at the present moment. I will state, however, before proceeding further, 
that the anginose and general symptoms which occur in cases beginning 
with violent nervous phenomena, and especially with convulsions, are 
nearly always of the most dangerous and malignant character, and usually 
end fatally in two, three, or four days after their appearance. 

The eruption in this class of cases varies according to the violence of 
the attack. In the severest one that I saw, that which proved fatal in 



SYMPTOMS OF GRAVE CASES. 497 

eighteen hours, no eruption whatever was perceived, and we only knew 
it to be scarlatina by the character of the other symptoms, and by the 
fact that the sister of the boy had been sick in the same house with the 
disease for a week. In the case which terminated in twenty-four hours, 
the eruption showed itself in the form of scarlet patches about the face 
and upper parts of the body, twelve hours after the onset. In the other 
eleven cases, which lasted, with one exception, not less than three days, 
the eruption was perfectly well marked. It covered the whole surface, 
was at first scarlet in color, soon ran into a deep red, and then became 
violet or purplish. The exceptional case was one which lasted thirty-six 
hours, and proved fatal in that time. In this also, the eruption was well 
marked and extensive. M. Gueretin (Arch. deJled., t. i. p. 292, 1842), 
in his account of the acute malignant form which he witnessed, states 
that the eruption was nearly constant. In all my cases it occurred within 
twenty-four hours from the invasion, while in those of M. G-ueretin, it 
appeared within twenty-four or forty-eight hours, or as more frequently 
happened, not until the fourth or fifth day. 

If no favorable change takes place in these severe cases, and when 
they do not prove fatal at once, the patient grows weaker and weaker; the 
delirium continues, or is replaced by coma ; subsultus tendinum, rigidity 
of the limbs, spasmodic twitchings or general convulsions, make their 
appearance ; the eruption becomes more and more livid ; the pulse grows 
smaller, more frequent, and irregular ; the respiration is excessively em- 
barrassed; deglutition becomes impossible; and the patient dies in from 
three to seven or nine days. In some few instances the child struggles 
on for several weeks, and dies in a state of utter exhaustion, or having a 
constitution of great powers of endurance, at last surmounts the disease 
and recovers. 

The invasion of grave cases is not always, as I have stated above, so 
violent as in those which have just been described. In rather more than 
two-thirds (28) of the 41 grave cases that I have seen, the onset was 
less threatening than in the other third, though the symptoms were 
severe and dangerous in most of these also, and when not so at the very 
start, very soon assumed the serious characters which make it necessary 
to class the cases in which they occurred as grave. The chief difference 
between the symptoms that mark the onset of grave cases of this kind, 
and of those in which the symptoms are still more violent, which latter I 
have thus far been describing, lies in the character of the nervous pheno- 
mena, — in the latter most severe, threatening and dangerous, consisting of 
stupor, coma, or convulsions, and in the former, merely excessive agitation, 
restlessness, heaviness, or stupor. In one well-marked case of the kind now 
under consideration, the patient, a boy between seven and eight years old, 

32 



498 SCARLET FEVER. 

was attacked in the evening with headache, fever, and vomiting. On the 
following morning a faint rash was perceptible, which, by the afternoon 
of that day was distinct, though not very full. The case now rapidly 
assumed unpleasant features. The pulse rose to 150. There was much 
drowsiness and delirium, and on the fourth day, constant picking at the 
bed-clothes, and at the fingers. In another case, in a boy between four 
and five years old, the first sign of sickness was slight languor after 
dinner, which was followed by fever in the evening, and the development 
in the course of the night of a scarlatinous rash. On the following day, 
there was some pain in the throat, with redness ) the pulse was 140 ; the 
skin was hot and dry; there were no nervous symptoms, except slight 
drowsiness. On the third day the pulse was 136, the rash was well out, 
and there were no unpleasant symptoms whatever. From this time, how- 
ever, the symptoms gradually grew worse ; — the throat-affection increasing, 
the cervical lymphatic glands becoming very much swelled, and the child 
becoming more uneasy and restless, though retaining perfectly its intelli- 
gence. By the sixth day, the grave character of the case was fully deve- 
loped, the eruption being intense, and of a deep brick-red, verging towards 
a purple color. There was at the same time very great drowsiness, abun- 
dant discharges from the nasal passages of thick sero-mucous and purulent 
fluids, membranous exudation in the fauces, with gurgling and great diffi- 
culty in swallowing, and an utter loss of appetite. In a third case, a boy 
between one and two years old was a little fretful in the morning, and 
was seized in the evening with vomiting and fever, and very considerable 
restlessness. On the next day he was covered with a scarlet rash from 
head to foot, and the skin was fiery hot. The pulse was 160, regular, 
not large. The child was very drowsy, dozing nearly all the time, but 
quite intelligent when aroused. The fauces were intensely red and 
rough, and the tonsils much swelled ; there was very little external swell- 
ing. On the third day he was still very drowsy, and when roused, less 
observant than before, though he still recognised persons. The pulse was 
168, small, difficult to count, very hard, and corded. The skin, especially, 
that of the limbs, was scarlet, very hot, and dry ; the cutaneous capillary 
circulation was good. After this the symptoms grew rapidly worse ; the 
pulse continued at from 148 to 168 on the fourth and fifth days, and on 
the sixth rose to 172, at which it stood a few hours before death. On 
the fourth and fifth days, he was still very heavy and drowsy, and so 
much so on the former as to take no notice whatever except when 
moved. On the fifth day, an abundant sero-mucous discharge took place 
from the nostrils \ the cervical lymphatic glands which had begun to swell 
before, now increased in size ; there was some loud faucial gurgling, and 
the swallowing became difficult. On the morning of the sixth day, some 
of the symptoms improved so much as to flatter very greatly some of his 



SYMPTOMS OF GRAVE CASES. 499 

attendants, who were unacquainted with the treacherous character of the 
disease. He roused up from his state of stupor, and noticed several things 
that were shown him, even taking them into his hand ; but the breathing 
continued bad, the lymphatic glands were swelling rapidly, and had 
already become very large, so that they formed great projections on either 
side of the neck. The pulse was 155, and small. In the middle of the 
day the breathing became difficult, from the internal and external swel- 
ling, and from the collection in the fauces of thick and viscid phlegm. 
The surface had now become pale. The tumefaction about the neck was 
immense. Down the front of the neck, and along its sides, to the clavi- 
cles, a kind of (edematous swelling of great size had come on, and was 
rapidly increasing. The pulse was 160, small, and feeble. The legs and 
arms were of a dark, congested tint. Deglutition was excessively difficult. 
In the evening the pulse was 172, and. death took place just before mid- 
night with slight convulsive movements. 

The mode of invasion is different, therefore, in different examples of 
the kind of grave cases now under consideration. In some it is even 
milder than in any of those that have just been detailed, and it is not 
until the third, fourth, or fifth day, or even later, that the severity of the 
attack shows itself fully and unmistakeably. 

After the disease is once established, it will be found upon examination, 
that the fauces are of a deeper red color, and that they are more swelled, 
than in mild cases. At the same time there is more difficulty and pain 
in deglutition ; these are complained of by older children, and are shown 
in those who are younger, by their refusal to swallow, by their crying 
upon making the attempt, and in some instances, especially at a later 
period of the sickness, by a positive inability to perform the movement. 
In nearly all of these cases, false membrane is thrown out upon the mucous 
membrane of the throat. This is never, or very rarely, present on the 
first day of the attack. In most cases it is not found until the second 
or third, and often not before the fifth or sixth day. MM. Rilliet and 
Barthez state that they have known it not to appear until the tenth and 
eleventh days. It appears first in small, thin, whitish, yellowish, or ash- 
colored points or patches, on one or both tonsils, or on the soft palate 
only, where it remains limited, or from whence it extends to the pharynx, 
which it may cover in whole or in part. The patches are of variable 
thickness and consistence, and adhere sometimes very slightly, and some- 
times with considerable tenacity to the mucous membrane beneath. They 
may remain for a day, and then be thrown off not to be again produced \ 
or they may form in several successive crops, until the case is terminated ; 
or, as most frequently happens, they last three or four days, or more, and 
are then detached. The mucous membrane upon which they are seated 



500 SCARLET FEVER. 

is found in various conditions. It may present the redness and swelling 
indicative of severe inflammation, or it may be softened, ulcerated, and 
according to Gruersant and Blache, gangrenous, though, as a general rule, 
what have been supposed to be sloughs are in fact portions of altered 
false membrane. There is more or less fcetor of the breath, sometimes 
amounting to a gangrenous odor, after the appearance of the pseudo- 
membrane. The severity of the symptoms is in proportion to the extent 
and thickness of the false membrane. 

We have already seen that it is not uncommon to find ulcerations 
beneath the false membranes. In other cases of this kind the throat- 
affection assumes very great violence without the presence of any exuda- 
tion whatever. In some the mucous membrane is of a deep red or even 
purplish hue, its consistence is softened, and it is swelled, and covered 
with a layer of grayish or sanious pus. The tonsils are enlarged, 
infiltrated with pus, softened, and break down easily under the finger. 
In other cases, in addition to the redness and softening, ulcerations are 
present. These may be superficial, amounting only to erosions, or they 
may extend through the mucous, and even submucous tissue, to the mus- 
cles beneath. They are seated generally in the pharynx, but may exist 
also in the tonsils, and in some rare cases they extend into the larynx. 
In still more malignant attacks of the disease, we find evidences of gan- 
grene of the pharynx. It is important to distinguish between those in 
which the pseudo-membrane becomes so changed as to assume the appear- 
ance of sloughs, and those in which the tissues of the pharynx are really 
gangrenous. The former constitute by far the greater number of the 
cases which have been generally regarded as instances of gangrene of the 
throat. That gangrene of these tissues does actually occur in some few 
cases, is proved, however, by the evidence of Dr. Tweedie, who says 
(Loc. cit. p. 650), that in malignant scarlatina "the membrane of the 
pharynx is sometimes of a dark, livid color, and occasionally in a slough- 
ing state," and by that of Gruersant and Blache (Diet, de Med., Art. 
p. 159), who state that they met with several instances of gangrene of 
the pharynx in the pseudo-membranous angina which prevailed in 1841. 

An almost constant accompaniment of cases of this kind is inflammation 
and swelling of the submaxillary lymphatic glands and surrounding 
cellular tissue. The tumefaction is generally confined at first to the 
glands beneath the jaw, which become painful to the touch. After a 
short time it extends to the parts behind the angle of the jaw, and 
beneath that bone, until at last the sides of the neck and the throat are 
largely distended, so as to interfere with or even prevent in great 
measure, the opening of the mouth, and, by the pressure it exerts 
on the internal parts of the throat, to add to the difficulty of deglutition 



SYMPTOMS OF GRAVE CASES. 501 

which already exists. In some cases the pressure is so considerable as to 
embarrass the respiration of the child. This swelling has been generally 
supposed to depend on inflammation of the parotid glands ) but MM. 
Bretonneau, Guersant and Blache, and Rilliet and Barthez, all state that 
parotitis is of exceedingly rare occurrence, and that the swelling in ques- 
tion depends nearly always on the causes just described. The last-named 
writers state, moreover, that the tumefaction of the cellular tissue is often 
of the nature of active oedema. The swelling of the cervical lymphatic 
glands, and of the cellular tissue of the sides of the neck, and that under 
the throat and chin, seldom takes place to any considerable extent, 
according to my experience, prior to the third or fourth day. During the 
first two or three days, the chief symptoms are the fever, the eruption, 
and the nervous phenomena, which latter consist, in this class of cases, 
of either excessive agitation and restlessness, or of drowsiness or stupor. 
Very often, after a child has seemed to be very ill for two, three, or four 
days, from the violence of the febrile reaction, and from the severity of the 
nervous symptoms, it will appear to improve very decidedly on the third 
or fourth day, and elevate greatly the hopes of those interested in it. It 
is just at this time, however, that the throat-affection is apt to set in 
severely, and, moreover, it rarely fails to come in children who have pre- 
sented violent symptoms during the first three days. The enlargement 
generally disappears, in favorable cases, in from three to twelve days, by 
resolution, while in others it terminates by suppuration of the glands 
and surrounding parts. 

In the form of the disease we are now considering, it is common to 
observe violent coryza, which may be either purulent or pseudo-membra- 
nous. It may appear from the very first, or not for several days after 
the eruption has commenced. The discharge is yellowish, granular, thin, 
very offensive, and highly acrid, so as to excoriate very much the upper 
lip. It sometimes flows in great abundance, and generally continues up 
to the moment of death, or until all the symptoms have moderated. 

Otorrhoea is another symptom of this form. It generally occurs 
simultaneously with the coryza. The discharge is at first thin and 
watery, like that from the nostrils, and becomes gradually thicker 
as the case advances. The quantity is extremely variable. In some 
cases I have known it to fill the meatuses and conchae of both ears, 
and then to flow out and make large stains upon the pillow, or to collect 
very rapidly after being wiped away. It is, like the coryza, an unfavor- 
able symptom, as it is a mark of the grave form of the disease, and 
because, if the child recovers, it is very apt to result in deafness, which is 
but too often permanent. 

These symptoms, coryza and otorrhoea, sometimes exist also in mild 
cases, but they do not then assume the peculiar characters which they 



502 SCARLET FEVER. 



: the 






present in grave cases. The discharges are much less abundant, and 
mucus or pus is healthy, and scarcely offensive to the smell ; they last 
but a short time, and are very rarely accompanied at the time, or fol- 
lowed, by more than a slight degree of deafness. 

The eruption is generally stated to appear later than in mild cases, and 
often to be less vivid and less extensive. It is also said to occupy only 
portions and not the whole of the body, to occur in irregular patches, or 
to appear and disappear alternately. This has not been the case in the 
instances which I have seen. In all but two of these, twenty-eight in 
number, the eruption occurred early, generally within twenty-four hours 
from the onset. It was of a deep brick-red or livid color, and covered 
the whole surface. In one of the exceptional cases it did not take 
place until the seventh day, when it appeared in patches on the wrists 
and knees. On the eighth day it extended to the rest of the extre- 
mities and abdomen and on the ninth was general, and of a rather dark 
hue. In the other exceptional case, the eruption did not appear until 
the second day. It then came out over the whole trunk, and to a mode- 
rate extent, upon the limbs also. In this, as in the previous one, it was 
dark in its tint. 

The general symptoms are more severe in grave than- in mild cases. It 
sometimes happens that for one or two days, or even longer, the case pro- 
mises to be mild, but then suddenly assumes the threatening features of 
the form under consideration. The fever is usually intense, the pulse 
being full and strong, and rising very soon after the onset to 140, 150, or 
170 : the skin is very hot and dry ; there is more restlessness and irrita- 
bility than in the regular form, and after one, two, or three days, appears 
a strong disposition to delirium and stupor, not unfrequently merging 
into coma. The respiration is accelerated, and in many instances, owing 
to the throat-affection, labored and difficult. In most of the cases, a loud 
gurgling, which is very characteristic, is heard in the throat, particularly 
when the child is asleep or dozing. This depends in part upon the col- 
lection of viscid and tenacious secretions in the fauces, — which sometimes 
embarrass the respiration so much as to make it necessary to remove them 
with a mop, or by the operation of an emetic, — and in part upon the exis- 
tence of the coryza of which we have spoken. The coryza is a symptom 
of very serious consequence in infants, as in them, it alone may cause 
death, and as it always adds very much to the danger. There is gene- 
rally some cough, which may be frequent and troublesome, though not 
usually so, unless there be a disposition to laryngeal complication. The 
voice is hoarse, guttural, and sometimes whispering. When the cough is 
very frequent, and still more, when it becomes hoarse and croupal, in 
connexion with hoarse or whispering voice, or aphonia, there is great 
reason to fear the extension of the exudation into the larynx, which con- 






SYMPTOMS OF GRAVE CASES. 503 

stitutes an almost fatal accident. The face is deeply flushed at first, and 
the expression anxious. If no improvement take place, the case assumes, 
in four or five days, or even less, a still more threatening aspect. The 
pulse becomes very rapid and small; the restlessness and delirium 
pass into drowsiness or coma ; the tongue becomes brown and dry ; the 
teeth are covered with sordes ; the lips are dry, cracked, and bleeding ; 
diarrhoea is apt to occur; and the patient dies in from three to ten days, 
in a well-marked typhous condition. In other instances, on the contrary, 
the case runs on from week to week, and at last, after an illness of four, 
five, or six weeks, the child either dies, or recovers, after all chances for 
life seem to have been lost. 

In order to show, in their natural connexion, the different symptoms 
that have just been described, I will cite the following abstract of three of 
my cases. The first occurred in a boy between seven and eight years old. 
On the fourth day of the attack the pulse was at 150, and the fauces pre- 
sented flecks of false membrane. The fauces were very much swelled, 
and deglutition became difficult ; faucial gurgling came on, and the throat 
was filled with viscid and tenacious secretions. The nasal passages now 
became occluded by constant discharges, at first mucous, and then 
muco-purulent, with admixture of membranous particles. From the 
fifth to the ninth day, there was an excessive fetor from the nose 
and mouth. The lymphatic ganglions just beneath the ear swelled 
very greatly, so as to extend much beyond the line of the inferior 
maxilla. The tongue and lips became dry and cracked, the teeth were 
covered with sordes, and the angles of the eyelids inflamed and then 
ulcerated. On the sixth, seventh, eighth, and ninth days, there were 
taken away from the mouth and throat of the child, with a mop, hard 
and most offensive masses of dried up mucus and incrusted epithelium, 
enveloped in thick, gluey, dark-colored mucus. These masses stuck to 
the fauces, tongue, and lips, so tenaciously, that they could be removed 
only by means of a mop, the boy himself being quite unable to detach 
them. On the seventh, eighth, and ninth days, though the cervical lym- 
phatic glands were very much swelled, the patient was better. The pulse 
came down gradually from 152 to 132, 128, and 112, and the swallow- 
ing improved so much that the child could take liquids with less convul- 
sive effort, and could drink continuously. The drowsiness diminished, 
and the delirium ceased. On the eighth da}* a slight erythematous redness 
appeared on the bridge of the nose, and extended towards the malar bones. 
The skin of the face and eyelids became somewhat swollen and puffed by 
an oedematous effusion. On the ninth day the pulse was down to 104, and 
the skin was nearly natural as to temperature. The swelling was very 
great on both sides of the neck, and the gland on the right side was red 
on the surface, very hard, and quite painful. The swallowing was much 



504 SCARLET FEVER. 



uld 

,rge 

v n. 



easier for drinks, but as yet no solid, not even of the softest kind, could 
be taken. On the fourteenth day from the onset, I opened a very large 
abscess on the left side of the neck, which discharged abundantly a 
healthy and laudable pus. On the fifteenth day, I opened a still larger 
abscess on the right side, and after this perfect recovery took place. 

In another example, which has been alluded to already, occurring in a 
boy between four and five years old, the gravity of the case did not show 
itself clearly until the sixth day. On the evening of that day the pulse was 
128, the skin very hot and dry, and there was an intense eruption of a 
brick-red color. There was, at the same time, great drowsiness, and utter 
loss of appetite. Deglutition was difficult, and there was a loud faucial 
gurgling during sleep. There was now also a considerable amount of 
membranous exudation in the fauces. During the seventh and eighth 
days, the boy continued very sick. He was drowsy, almost comatose; 
indeed, the eyes were half open and the conjunctiva minutely injected; 
there was an abundant coryza, the discharges being composed of offensive 
mucous and sero-mucous fluid, with an admixture of pus and of flocculent 
or grumous particles, the latter consisting evidently of broken-down mem- 
branous exudation. There was no otorrhoea. The pulse rose from 120 to 
128. During the night of the seventh day, the anginose affection was so 
severe that the child could swallow nothing from 10 p.m. to 3 a.m. ; what 
was put in the mouth ran out again in part, and was in part returned 
through the nostrils. On the tenth day there was still no decided im- 
provement, except that the pulse had fallen to 112. The coryza con- 
tinued as before ; the fauces were covered thickly with whitish exudation ; 
the deglutition was a little easier. The drowsiness continued, as the 
child dozed nearly all the time, merely rousing from time to time to take 
drinks, and then, in spite of all solicitation, sinking into sleep again. 
The abdomen was tympanitic. The urine was rather free, more so than 
it had been before, and it was also clearer and of a lighter color. By the 
twelfth day, there was a decided improvement. The pulse had fallen to 
106, and the child was not quite so heavy. The act of swallowing was 
easier, and the fauces showed less of the plastic exudation, but they were 
still very much coated with tenacious mucus. On the thirteenth and 
fourteenth days, the patient continued to mend. The pulse fell to 98 and 
92 ; the fauces had become clear of the exudation, and presented instead 
an excoriated and ulcerated appearance. The secretions into the fauces 
were less viscid and less copious. The coryza had diminished, and the 
discharges had become first muco-purulent, and then mucous. The drow- 
siness had diminished, so that he waked spontaneously, and began to ask 
for his toys. He now began to demand food, but refused to eat when 
things were brought to him. On the fifteenth day he was extremely irri- 
table, screaming most violently for the slightest causes. On the sixteenth 



SYMPTOMS OF GRAVE CASES. 505 

day the pulse was 92, and the skin nearly natural as to temperature. 
He was now exceedingly emaciated and very weak. The orifices of the 
nasal passages were very much irritated and incrusted, but there was 
scarcely any coryza. The tongue was clean, pink in color, and moist, 
the thirst not too great, and there was a little appetite. The temper was 
improving. From this time forward the child improved steadily but 
slowly, so that he sat up for the first time on the twenty-seventh day. 
He was as much emaciated at that time as after violent typhoid fever. 

The reader must not, however, suppose that all grave cases present 
throughout their whole course, symptoms as dangerous as those which 
marked the two examples that have just been detailed. In some, on the 
contrary, the symptoms, though of such a character as to deserve and re- 
quire the title of grave, are of a much milder kind. In order to make this 
part of my description of the disease as perfect as possible, I will relate the 
following as an example of a grave case in which the symptoms, though 
severe, were neither malignant, nor at any one time very dangerous to 
life. A girl between seven and eight years old was well at breakfast. 
In the course of the morning she complained of sore throat, and of not 
feeling well, and at 4 p. M., when I saw her, was quite feverish, with a 
frequent pulse and hot skin, and showed already a well-marked, but rather 
faint scarlet rash upon the trunk of the body, and about the elbows. On 
the following day the trunk and upper parts of the limbs were covered 
thickly with an intense eruption, of a bright scarlet color. The fauces 
were very red, somewhat roughened, and a good deal swelled. The only 
nervous symptom present was severe frontal headache. There was no 
unusual agitation, no drowsiness, and nothing like convulsive movement. 
On the evening of this day, the pulse had run up to 168, and it was rather 
full, but not hard. The skin was exceedingly hot and burning; during 
the night there was great restlessness, and the child was wakeful and 
occasionally delirious. On the third day the symptoms continued much the 
same, except that the pulse was down in the morning to 152, that the 
rash had extended to the hands and feet, and that some small spots of 
whitish exudation were now visible on each tonsil. On the night of this 
day the fever again increased very much, and the child was again delirious. 
On the fourth day the pulse was 148 ; the exudation had increased so much 
as to cover a good portion of both tonsils, and it had extended also in a slight 
degree to the posterior wall of the pharynx. There was now a considerable 
enlargement of the lymphatic glands situated at the angle of the jaw on 
the left side, and a smaller one on the right side. Deglutition was some- 
what painful, and a little difficult, but not seriously so. The case conti- 
nued in much the same way until the seventh day, when the pulse had 
fallen to 132, and the eruption had faded very much on the trunk of the 
body, and to a considerable extent, upon the limbs also. The fauces now 



506 SCARLET FEVER. 



exhibited the false membrane over the whole of both tonsils, over the 
half-arches, the sides of the uvula, and upon the upper portion of the 
posterior wall of the pharynx. Instead of being whitish and clean-looking as 
at first, however, the false membranes now looked exactly like sloughing 
portions of the mucous membrane. They were of a dirty brown color, 
softened, and seemed to be detaching themselves like sloughs from 
the tissues beneath. On the ninth day the patient was much better, the 
pulse having fallen to 116 ; the eruption had almost wholly disappeared; 
the heat of skin was very much reduced; the dark-colored portions of 
false membrane had disappeared from the fauces, leaving the mucous 
membrane beneath, red, excoriated, and in parts ulcerated. On the 
thirteenth day, the child was convalescent, the pulse having fallen to 96, 
the heat of skin having disappeared, and the throat being nearly well. 
The appetite had returned, the temper was serene and cheerful, and the 
patient was, in fact, well, with the exception of weakness, and some remain- 
ing soreness of the throat. 

Laryngitis has been supposed by some persons to be of frequent occur- 
rence in the course of the disease, while others assert that it rarely, if 
ever, occurs. Bretonneau has never met with it. Bayer says he does 
not know that the exudation has ever been found in the larnyx or trachea. 
Tweedie {Cyclop. Pract. Med. Art. Scarlatina, p. 640) states that in the 
dissections he has made he has not seen an instance of the membranous 
exudation extending into the larynx. That it does sometimes occur, is 
proved nevertheless, beyond a doubt, by the evidence of MM. Guersant and 
Blache, Rilliet and Barthez, and others, and by my own observation. 
Billiet and Barthez report three cases it which it was found in the larynx 
after death. These gentlemen state, however, that they have never ob- 
served the peculiar symptoms of croup. This does not accord with my 
own experience, for in one of the cases that I have seen, all the peculiar 
symptoms of that malady were present during life. The subject of this 
case was a boy two years of age. A few days after the invasion of the 
disease, a severe and extensive pseudo-membranous angina was developed. 
This was soon followed by all the symptoms of croup, — hoarse cough, 
stridulous respiration, weak, feeble cry, dyspnoea, and whispering voice, 
which lasted about five days, when the angina and croupal symptoms both 
diminished very much, and the child seemed in a fair way to recover: sud- 
denly, however, extensive tumefaction of one side of the neck took place, 
and he died in twenty-four hours. Unfortunately no examination could 
be made. In another case, in a child between six and seven years old, who 
had a most violent attack of the disease, severe croupal symptoms set in on 
the eighth day. They consisted of harsh, croupal cough, stridulous respira- 
tion, and great difficulty in swallowing, and the act of swallowing occasioned 
much harsh cough and strangling. The symptoms continued on the ninth 






DURATION. 507 

day, after which they moderated and the child finally recovered entirely. In 
a third case, also a violent one, in a boy between eight and nine years old, and 
in which general convulsions occurred on the first and second days, the symp- 
toms had improved a good deal on the third and fourth day. On the fifth day, 
he was not so well, being more restless and heavy, and having much diffi- 
culty in breathing, with some croupiness of sound. These symptoms in- 
creased rapidly until they gave rise to most violent fits of suffocation, and 
caused a fatal termination on the sixth day. In a fourth case, in a child 
nine months old, death occurred on the thirteenth day from laryngitis 
occurring in connexion with membranous angina. The fatal termina- 
tion was preceded by hard, dry, and croupal cough, stridulous respiration, 
and great difficulty of deglutition. In a fifth, in a child under a year 
old, croupal symptoms made their appearance on the sixth day, the fauces 
being at that time covered with membranous exudation, and they caused 
or assisted to cause a fatal termination on the eighth day. In yet another 
case, the subject of which was between one and two years old, a grave at- 
tack of scarlet fever was entirely recovered from. At the end of the second 
week the child was seized, owing to improper exposure in a cold house, 
against which the parents had been properly warned, with anasarca. 
This also was recovered from, and again the parents were warned against 
improper exposure. On the very day after my last visit, however, the 
child was taken down stairs into a room with the windows open, and 
this on a mild day in the month of February. The child was seized 
now with diphtheritic angina and died, after a few days, of croup. 
This was in the fourth week from the onset of the scarlet fever. In a 
seventh case, severe from the beginning, the patient recovered so as to 
be apparently out of danger, but, owing to the room being very cold from 
the fact that it was large with wide rattling windows down to the floor, 
and from the fire being too small, the child took cold, and at the end of the 
third week, was seized with severe croup, which had many of the features 
of membranous croup, but which was, in all probability, spasmodic croup, 
dependent on ulcerative laryngitis. The case continued seven days, dur- 
ing which time the patient was violently ill, but finally, after a most dan- 
gerous struggle, it ended favorably. 

The symptoms which indicate a disposition to implication of the larynx 
are frequent, hoarse, and croupal cough, hoarse and whispering voice or 
cry, aphonia, and dyspnoea with stridulous respiration. 

The duration of grave cases of scarlet fever is very uncertain. In some 
the disease runs it course with frightful rapidity, destroying life within a 
few hours or days. In others, though the symptoms of the early stage 
may seem to be as violent as in those, where death occurs in a very short 
space of time, the patient either lingers for several days or two or three 
weeks, and then dies, worn out by the violence or malignancy of the 



508 SCARLET FEVER. 

attack, or else, after a most dangerous and perhaps apparently desperate 
illness, he finally struggles through and recovers. 

In the most violent of the grave cases, those which I described first as 
forming a separate group, 13 in number, of which 10 proved fatal, the 
duration in the fatal cases was between 18 hours and G days. Of the 10, 
one proved fatal in 18 hours, one in 24 hours, one in 36 hours, four in 3 
days, one in 4 days, and two in 6 days. Of the three favorable cases, one 
lasted 3 weeks, and two 6 weeks. 

Of the less violent of the grave cases, 28 in number, 13 died and 15 
recovered. Of the 13 fatal cases, one died in 4 days, two in 5 days, two 
in 7 days, two in 8 days, one in 13 days, one in 14 days, one in 15 days, 
two in 4 weeks, and one in 5 weeks. Of the 15 favorable cases, the du- 
ration of the shortest was 7 days ; one lasted 12 days, one 16 days, five 2 
weeks, three between 2 and 3 weeks, two 3 weeks, and two 6 weeks. 

Complications and sequelae. — Dropsy. — This is one of the most frequent 
and important sequelae of the disease. It occurred in a fifth of the cases 
of MM. Killiet and Barthez, and in 22 of the 185, or in rather less than 
an eighth of those observed by myself. It occurs generally in the course 
of the second or third week of the disease, and during the process of de- 
squamation. It is thought to follow cases of moderate severity much 
more frequently then those of a grave character. Dr. Tweedie states that 
it has never been observed to succeed a malignant attack. This does not, 
however, accord with my own experience, since of the 22 examples that I 
have seen, 5 occurred in grave cases of the disease. The effusion may 
attack any one of the cavities or the cellular tissue of the body, or all 
at once. The most common form in which it appears is anasarca, after 
which the most frequent are, in the order in which they are mentioned, 
oedema of the lung, hydrothorax, ascites, hydropericardium, and hydro- 
cephalus. 

The exciting cause of the dropsy is generally believed to be cold, 
contracted usually by exposure to air and moisture, at too early a period. 
I have rarely known it to occur when the patient has been confined to the 
chamber or house until after the twenty-first day ; while, on the other 
hand, I have seen it follow immediately upon a ride in cool weather on the 
fourteenth day, the child having apparently been convalescent for several 
days before. I have known it to occur also when the child has been al- 
lowed to run through the house exposed to draughts from open doors and 
windows. 

I have been able, in a number of instances, to trace it directly and ob- 
viously to cold. Thus, in one very marked example, a boy between six 
and seven years old had had a mild attack of the disease, and was so entirely 
recovered that I ceased my visits on the tenth day, leaving strict injunc- 
tions with the mother as to the necessity of confining the child to the 






SEQUELiE — DROPSY. 509 

house for at least ten days longer. On the fourteenth day, he was allowed 
to sit for fifteen minutes, late in the afternoon of a cool April day, on the 
marble front-door step. He was seized that night with fever and vomit- 
ing, was anasarcous next day, and during an illness of two weeks had 
dropsy of the pericardium, effusion into the right pleural sac, ascites, and 
some signs of hydrocephalus. In another case, a boy eleven years old 
had recovered entirely of a mild attack. He slept in a room heated by a 
stove. On the nineteenth day, the weather being cold, he got up early in 
the morning to light the fire which had gone out accidentally. He was 
attacked that day with bronchitis and was, on the following day, anasar- 
cous. In another instance, anasarca was produced at the end of the 
third week, the child being quite well previously, by his being taken into 
a cold room to sleep. I could cite other instances of the same kind, but 
these are enough. It is sufficient to say that in a large majority of the cases 
that I have seen, it has manifestly and obviously followed improper expo- 
sure during the second or third week. In a few cases, however, it has 
come on without any imprudence whatever, and 1 have been entirely una- 
ble to ascertain the cause. 

I am in the habit now of always directing the mother or nurse to keep 
the patient confined to the chamber for three weeks from the onset of the 
disease, or, if it be allowed to run through the house, to take care to have 
it well clothed, and to keep the windows and doors carefully closed should 
the weather be cold or cloudy. 

There has been a good deal of discussion in regard to the exact patho- 
logical cause of scarlatinous dropsy. Some observers assert that it de- 
pends on Bright's disease of the kidney, while others are of opinion that 
it ought not, on account of its ready curability in most instances, to be 
referred to that disease, since that is so well known to be nearly always 
incurable. MM. Rilliet and Barthez state that they found the character- 
istic renal lesions of Bright's disease in more than half of all their cases 
of dropsy, and in more than two-thirds of those of anasarca. Fre- 
richs, also, whose opinions on this subject are, perhaps, the most authori- 
tative of all, asserts that the kidneys after death from scarlatinoid albu- 
minuria exhibit the lesions characteristic of the first and second stages of 
Bright's disease. He "rejects in toto the opinions entertained by Drs. 
Johnson, Todd, and others, with reference to the occurrence of a disease 
subsequently to scarlet fever, to which the term desquamative nephritis 
can be applied." (Brit, and For. Med.-Chirurg. Eev. y April, 1852, p. 
241, Am. Ed.) M. Legendre, on the other hand, who has studied the 
subject with much care, is of opinion that " we ought to refer the altera- 
tions exhibited J?y the kidneys as well as the functional disorders con- 
nected with those alterations only to ordinary nephritis, or perhaps to 



510 



SCARLET FEVER. 



simple congestion of the kidneys." (Rccherclies Anat. — Pathol, et Clin., 
sur quclqucs Mai. de V Enfancc, p. 320.) 

The dropsical symptoms usually show themselves in the third or fourth 
week of the disease. In most of the cases that I have seen they occurred 
in the third week, but they sometimes appear at the end of the second, 
and sometimes not until the fourth week. They occur, therefore, as a 
general rule, during the stage of desquamation. The attack is sometimes 
very sudden, but in most instances it is slow and gradual. The effusion is 
not commonly the first symptom observed. On the contrary, the dropsy 
is almost always preceded for one or two days, by the signs of a more or 
less considerable constitutional disturbance. The patient has usually 
passed safely through the eruptive stage of the fever, and has been con- 
sidered for several days, sometimes for a week or ten days, as conva- 
lescent, for, be it remarked, the dropsical affection is much more rare 
after grave than after mild cases. The child has perhaps been running 
about the house, or it has even been out, the parents supposing, unless 
warned by the physician, from the disappearance of the fever and other 
symptoms of illness, and from the return of appetite and gaiety, that 
complete recovery has taken place. But, either after some exposure, and 
sometimes without any appreciable cause, the child becomes drooping, 
languid, and irritable, or uneasy, peevish, and restless. Simultaneously 
with or very soon after these symptoms, fever sets in ) the skin becomes 
dry and heated ; the pulse is frequent and hard, or it is frequent and 
jerking; the appetite is diminished or lost, and there is more or less 
thirst ; the bowels are generally constipated ; the urine is usually dimi- 
nished ; and there is not unfrequently some nausea or vomiting, and com- 
plaints of headache. 

The symptoms which precede the appearance of the effusion are not 
always, however, so marked, while in other instances they are scarcely 
noticeable, and yet the effusion may take place suddenly, and, affecting 
the subcutaneous cellular tissue and different internal organs simulta- 
neously, may cause a fatal termination with frightful rapidity. 

The effusion usually commences in the face, which becomes slightly 
swollen. The amount of the effusion is sometimes very slight, leaving us 
in doubt even whether there really is any or not. The swelling is most 
marked about the eyelids, which look puffed, and it may be confined en- 
tirely to them, or, at least, it may be only in them that we can feel sure of 
its existence. From the face it extends to the hands and feet, and either 
remains limited to these parts, or spreads over the whole surface, and 
gradually or rapidly, to the internal organs. The skin over the parts in 
which the effusion has taken place is firm, hard, and elastf c to the touch ; 



SEQUELAE— DROPSY. 511 

it does not generally pit, at least not in the early stage, and it is of a dull 
white color. 

In very mild cases the constitutional disturbance is usually but slight, 
and the effusion may be so small in such instances, as to leave us in 
doubt as to the cause of the sickness. Generally, however, I have been 
able to determine the cause of the fever by a careful examination of the 
face, and particularly of the eyelids, which look a little swelled and dis- 
tended, and by the presence of a slight puffiness or cushiony appearance 
of the backs of the hands and feet. In such cases the general symptoms 
generally pass away after a few days ; the urinary secretion, which had 
been diminished in quantity and of a deeper color than natural, becomes 
again healthy ) the anasarca disappears, and the child returns to its ordi- 
nary condition. In more severe cases the general symptoms are all more 
marked ; the anasarca is more extensive and the swelling more conside- 
rable ; the child, if old enough to describe its sensations, complains of 
pain in the back, and the lumbar region is tender to the touch ) the urine 
exhibits much more marked changes in its characters ; but still, unless 
some important internal cavity be attacked, the symptoms diminish after 
a week or ten days, and the child recovers gradually. In still more vio- 
lent cases, the amount of the effusion is very large indeed, the face is 
disfigured by the swelling, the limbs are largely distended, the cellular 
tissue of the trunk of the body is infiltrated, the quantity of urine dis- 
charged is very small or the secretion is arrested entirely for one or 
several days, and the fever is high. If the disease is not removed, the 
effusion may extend to the internal organs : to the lung, producing oedema 
of that organ, to the pleural sac, causing hydrothorax, to the pericardium, 
to the peritoneal cavity, or to the brain. Death may occur in these vio- 
lent cases from asphyxia occasioned by oedema of the lung, by hydro- 
thorax, or by the obstacle to the circulation caused by the presence of the 
effusion in the pericardium, from hydrocephalus, or the patient may sink 
into a comatose state like that which often precedes the fatal termination 
of Bright' s disease in the adult. 

It sometimes happens, as was stated above, that death occurs with very 
great rapidity. MM. G-uersant and Blache have known it to end fatally in 
twelve, fourteen, and thirty-six hours. In a case that came under my own 
observation in consultation, a child between one and two years old, who 
had had a very mild attack of scarlet fever, was seized suddenly towards 
the end of the third week, after it was supposed to be quite well, and after 
exposure to draughts of cold air in the lower room of a small house, with 
vomiting, and shortly afterwards with convulsions and coma, which ter- 
minated fatally in thirty-six hours. 

The symptoms which mark the occurrence of internal effusion will de- 



512 SCARLET FEVER. 






pend of course upon the part attacked. In one case they will be those of 
oedema of the lung, in another those of hydrothorax, in another those of 
hydropericardium or ascites, or lastly, those of hydrocephalus. 

The particular condition of the urinary function is next to be described. 
It has already been stated that the amount of urine secreted is less than 
natural- during the early period of the dropsical attack. But, while this 
is true, it ought to be observed that the patient often voids the secretion 
more frequently then usual. There is in fact micturition, a symptom occa- 
sioned no doubt by the heated and irritating character of the urine, which 
causes the bladder to contract and expel that fluid as soon as even a small 
quantity collects. The diminution in the amount of the secretion is 
sometimes a very marked symptom. It is sometimes almost or even en- 
tirely suppressed for a considerable period. In one case that occurred to my- 
self, in a boy between one and two years old, there was no discharge what- 
ever for a period of thirty-six hours. During this time there was no dis- 
tension of the bladder, as I ascertained this point by careful palpation and 
percussion. In another case, which occurred in a girl between three and 
four years old, and who was nursed by the grandmother, one of the most 
accurate, reliable, and experienced nurses in the city, I was assured that 
there was no discharge whatever of urine for five days in succession. Du- 
ring this suppression there was no accumulation in the bladder. On the 
contrary, the hypogastric region was flat, depressible, and sonorous on per- 
cussion. The patient was very ill during all this time. She was feverish and 
passed nearly the whole time in a semi-comatose state, but could be roused 
with much effort, so as to 'show some intelligence ; she rejected by vomiting 
almost everything that was given her, and complained when aroused of 
severe headache. She had no convulsion nor any convulsive movements, 
and finally recovered as the kidneys regained gradually their secretory 
function. 

In very mild cases of dropsy the urine is usually of a deeper color than 
natural, but still retains its transparency when first voided. It is apt, 
however, to become turbid on cooling, and to deposit a more or less 
abundant precipitate. It has in these cases an acid reaction ; its specific 
gravity is somewhat increased; when heated, it becomes cloudy, and a 
small amount of a flocculent precipitate falls to the bottom of the tube or 
spoon. In severer cases the urine is very much diminished in quantity ; 
it may be merely of a dark red color, but more commonly it is blackish or 
brownish in tint, or it is of the color of smoke or soot; it throws down a 
deposit which is generally of a reddish-brown color ; when heated it yields a 
very large amount of coagulated albumen. If the spontaneous deposit 
be examined with the microscope in these cases, it is found to consist of 
crystals of the lithate of ammonia, of blood globules, scarcely altered, 



SEQUELAE. 513 

and of mucous corpuscles and epithelial scales. The discoloration in black 
or its shades, above described, depends evidently on the presence of blood 
in the urine. This has been ascertained by the use of the microscope. 

M. Legendre states that in fourteen cases analyzed by him, the urine 
was always coagulable by heat and nitric acid. The precipitate varied, 
however, in quantity and appearance, according to the color of the urine, 
and the distance of time from the invasion of the anasarca. Very 
abundant when the blackish or reddish color indicated the presence of a 
large quantity of blood, the coagulum diminished as the urine became 
lighter colored. When the urine contained much blood, the precipitate 
consisted of a number of flocculi, which fell rapidly to the bottom 
of the tube ; when, on the contrary, the amount of blood was small, the 
urine being of a pale yellow color, the precipitate, caused at the moment 
of boiling, merely gave an opaline tint to the fluid, and as the boiling 
was continued, furnished a delicate coagulum, which subsided very slowly. 
The color of the precipitate is said not to be of a pure white color as in 
Bright' s disease, but of a dirty brown or ash gray tint. 

The form which the dropsy takes varies greatly in different cases, 
and seems to depend on inappreciable causes. Of the 22 cases that I have 
met with, anasarca alone was present in 16. In 4 hydrocephalus 
was added to the anasarca. In one there were some symptoms which 
indicated the probable existence of a small amount of effusion in the 
brain, but they were not at all violent. Lastly, in one, there was ex- 
tensive anasarca, hydrothorax of the right side, hydropericardium, and 
ascites. 

The degree of danger to be apprehended from this complication depends 
upon the form which it assumes. Cazenave (Loc. cit. p. 52) says that 
there is no danger from it so long as it remains confined to the sub- 
cutaneous cellular tissue, and this is probably true. When, however, it 
attacks the brain or lungs it becomes exceedingly dangerous. Dr. Wood 
(Pract. of Med. vol. i., p. 403) says that he has seen but one fatal 
case from dropsy, and in that the heart was diseased. Of the 22 cases 
that I have had under charge, 5 were fatal. Of the 16 cases in which 
the effusion was anasarcous alone, but one was fatal. All of the 4 in 
which hydrocephalus occurred in connexion with the anasarca, ended 
fatally. In one case there were present well-marked but rather slight 
symptoms of hydrocephalus. This one ended favorably. In the last 
case to be adverted to, that in which hydrothorax, hydropericardium, and 
ascites were added to the anasarca, the patient recovered after a long and 
severe illness. 

In addition to the cases of dropsy just referred to, and which all occur- 
red in my own practice, I have seen two examples of hydrocephalus in 

33 



f)14 SCARLET FEVER. 

consultation, one of which came on very suddenly in a young child and 
proved fatal in thirty-six hours, while the other terminated favorably 
after a severe illness of nearly two weeks. In the latter case, the patient, 
a girl between three and four years old, was in a semi-comatose state for 
a week, with fever, excessive irritability of the stomach, and complaints 
of headache. For a period of five days the urine was entirely suppressed, 
not a drop having been voided during all that time, at least with the know- 
ledge of the nurse, who was a most accurate and competent person. It 
would seem to be much more dangerous in the Parisian hospitals than 
in private practice in this country, since Guersant and Blache speak of 
having seen it prove fatal in twelve, fourteen, and thirty-six hours, after 
one or two weeks, or even two or three months ; and Rilliet and Barthez 
refer to it as often proving fatal. 

Diarrhoea is not an uncommon accident of the disease. It generally 
depends on simple functional derangement of the bowels. In some cases, 
however, it is so severe or long-continued as to constitute a serious com- 
plication. Under these circumstances, it depends on follicular entero- 
colitis, slight erythematous inflammation, or simple softening of the in- 
testinal mucous membrane. 

Bronchitis and pneumonia are rare. Inflammation of the serous mem- 
branes is more common, occasioning in some cases the dropsical effusions 
which have already been treated of. Scarlatina may be coincident with 
variola or measles. I have never seen it in connexion with the former, 
but in two cases which came under my observation it was complicated 
with measles. 

Anatomical Lesions. — The eruption sometimes disappears entirely 
after death, and on other occasions assumes a deep livid or purple appear- 
ance. The epidermis is generally loosened upon the integument, so as to 
be peeled off with great facility. The most important lesions, and those 
which seem to belong to the nature of the disease independent of com- 
plications, are congestions of different parts of the body, particularly the 
brain, serous membranes, spleen, glands of Peyer, and intestinal follicles. 
It is a curious fact that, even when the cerebral symptoms have been 
most severe, and we might expect to find evidences of violent inflamma- 
tion of the brain, nothing is observed after death, in the majority of cases, 
but congestion of the large veins and sinuses of the brain, of the pia 
mater, or of the cerebral substance. There is rarely any unnatural 
amount of serous effusion into the ventricles, or meshes of the pia mater. 
Dr. Tweedie says, "indeed, we have frequently been surprised, in examin- 
ing rapidly fatal cases, to find no morbid appearances that could explain 
the cause of death." Nevertheless, effusions within the cranium some- 



DIAGNOSIS. 515 

times exist, as has been already stated in the remarks upon hydro- 
cephalus. 

The respiratory organs are usually healthy, with the exception of con- 
gestion and serous engorgement. The abdominal viscera often present 
appearances analogous to those of typhoid fever. The glands of Brunner 
and Peyer are not unfrequently enlarged, and they are sometimes reddened 
or softened. In a smaller number of cases the mesenteric glands are 
slightly inflamed and increased in size, and the spleen is redder than usual 
and softened. These lesions have no necessary relation to the form of 
the disease, since they are often absent in typhoid cases, and present in 
those of a different type. 

The kidneys are healthy, with the exception of some degree of conges- 
tion, unless the case has been complicated with dropsy. Under these 
circumstances they often present the characteristic lesions of Bright's 
disease. 

The blood presents very different appearances in different cases. It is 
viscid or serous, dark-colored or light, and fluid or coagulated, the clots 
being of variable color and density. The proportion of its constituent 
elements is changed. The fibrine maintains its usual relation to the mass 
of the fluid (3 parts in 1000), or it is very slightly augmented, while the 
quantity of the globules is increased to 136 or 116, according to Andral, 
instead of 127, in 1000 parts. 

Diagnosis. — It seems to me impossible to distinguish scarlatina from 
the other eruptive fevers by the symptoms which precede the erup- 
tion. The only signs upon which a diagnosis at that time might be 
grounded, are great frequency of pulse, which is characteristic of this 
disease, some soreness or redness of the fauces, and the prevalence of the 
disease in the community. But these are all exceedingly fallacious, and 
the physician should be content to wait for the eruption before he ven- 
tures to speak with certainty. After the eruption has come out it can 
scarcely be mistaken for anything else. 

From measles it may be distinguished by the differences in the pro- 
dromes, course, and eruption of the two affections. The prodromic stage 
of scarlatina rarely lasts more than twenty-four hours, and is very often 
much less ; that of measles, on the contrary, is almost always from three 
to four days ; in scarlatina the rash appears suddenly and is often com- 
pleted in a single day ; in measles it appears on the face first and extends 
gradually to the rest of the surface, seldom reaching the hands and feet 
before the end of the second day; the eruption of measles occurs first in 
distinct papulae, which coalesce and form patches of an irregular crescentic 
shape, while that of scarlatina is in the form of innumerable minute dots or 
punctuations, placed so closely together as to give to large portions of the 



516 SCARLET FEVER. 

surface a uniform color, like that produced by blushing. The color of 
the two eruptions is different, that of measles being dark like raspberry 
juice, and that of scarlatina of a more or less bright scarlet tint. The 
presence of catarrhal symptoms in measles and their absence in scarlet 
fever; the absence of angina in the former disease, or its very slight 
character, and the severity of the throat-affection in scarlatina ; and lastly, 
the greater severity of the febrile symptoms, particularly the frequency of 
the pulse and the heat of skin in scarlatina, are other points of difference 
which will assist in making the diagnosis, rarely, it seems to me, difficult, 
still more certain. A very great frequency of the pulse is one of the most 
unfailing symptoms of the early stage of scarlet fever. It almost always 
runs up to 140, 150, or 160, in young children, within the first twelve or 
twenty-four hours, and to 120, 130, 140, or higher, in those who are older. 
Nevertheless, this, like all other symptoms, is sometimes wanting. I have 
lately seen a boy, between five and six years old, with a marked but very 
safe attack of the disease, whose pulse ranged between 80 and 90 through- 
out the sickness. This was, however, the only case that I have ever met 
withj in which the pulse remained so little disturbed. 

It is sometimes very difficult to determine with precision between 
roseola and scarlet fever. By the eruption alone, I believe it to be often 
impossible. I have seen quite a number of cases in which the eruption 
of roseola resembled so closely that of scarlet fever, that I should have 
been obliged to confess my inability to make the distinction, had it not 
been for the other symptoms, and particularly the frequency of the cir- 
culation, the heat of the skin, and the throat symptoms. The most im- 
portant differential symptoms are the tint of the eruption, which in roseola 
is rose-colored, in scarlet fever, bright red or scarlet; the characters of the 
patches of eruption, which are more regular in shape, but of much smaller 
size in roseola than in scarlet fever ; the absence or very slight degree of 
anginose inflammation in roseola ; and, what is decidedly the most impor- 
tant of all, the very much slighter degree of febrile reaction in roseola, in 
which the pulse, instead of being doubled in frequency as it is in scarlet 
fever, is scarcely above its natural rate, and in which the heat of skin is 
but little above the standard of health. Moreover, roseola is generally of 
shorter duration, and is a milder affection, and therefore accompanied by 
far less fever and general disturbance of the constitution. 

Prognosis. — It is impossible to obtain a useful average mortality of 
scarlet fever, since the disease varies so greatly under different circum- 
stances, that the results obtained during one period are inapplicable to 
eases observed at another. This is proved by the experience of almost 
every physician, and by the evidence of many writers. It is proved, also, by 
the following facts. M. Gueretin (Loc. cit. p. 283) states that the mor 






PROGNOSIS. 517 

tality in the epidemic observed by him was about one in twelve : of 99 
cases, 8 died. MM. Killiet and Barthez lost a little more than half their 
cases : of 87 the total, 46 were fatal. These cases, let it be remarked, 
however, occurred in the hospital for children in Paris, which will ac- 
count for the heavy fatality. Of the 185 cases that I have seen, 24, or 
rather more than one-eighth, were fatal. Of the 185 cases, 104 occurred 
in and since the year 1849, and in these the mortality was much smaller 
than in those which occurred prior to that year. Of the 104, 11 were 
fatal, or about one in nine and a half. Of the 81 cases which occurred 
previous to 1849, 13, or about 1 in 6, proved fatal. 

The prognosis must be based, therefore, in part on the character of the 
epidemic that may be prevailing at the time. It must depend also on the 
nature of the case. Mild and regular cases are rarely fatal. Of 144 mild 
cases that have been under my care, only one proved fatal, and this need 
not have so terminated had it not been for the imprudence of the nurse. 
This was, in fact, the case of a young child, who had recovered from the 
eruptive stage of the disease, but whom the nurse carried out of the room 
in the second week, notwithstanding express directions given her to the 
contrary. The child took cold, and was seized with catarrh and slight 
anasarca ; on the fifteenth day, symptoms of hydrocephalus set in, and 
he died on the seventeenth day, comatose, and with convulsive movements 
of different parts of the body. 

Grave cases of scarlet fever are always, on the contrary, exceedingly 
dangerous, since of 41 cases of this kind that I have had under charge, 
23, or a little over a half, were fatal. In order to render the description of 
the symptoms of this class of cases more clear, I divided them into two 
groups ; one, in which the onset of the disease is instant and most vio- 
lent, being characterized by excessive disturbance of the nervous system, 
taking the form usually of convulsions, but sometimes only of profound 
coma j and a second, in which the symptoms of the onset, though severe 
enough usually from the first to mark the character of the case as grave, 
are less violent than in the first group, and especially not marked by 
the occurrence of convulsive phenomena. Of 13 cases belonging to the 
first group 10 died ; while of 28 belonging to the second 13 died. Violent 
nervous symptoms occurring early in scarlet fever augur, therefore, great 
danger to the patient, since of 13 cases in which they were present, 10 
died, whilst of 28 in which they were more moderate, though still marked 
and severe, only 13 died. 

The character of the nervous symptoms is, therefore, all-important in the 
determination of the prognosis, as the probable termination of the case is to 
be foretold more certainly by a just appreciation of these particular pheno- 
mena of the disease, than by any other means. Excessive jactitation or 



518 SCARLET FEVER. 

irritability, delirium, coma, and the hydrocephalic cries, are all unfavorable 
symptoms, but not in the same degree as are those connected with the 
locomotive apparatus. MM. Rilliet and Barthez state that they have seen 
recoveries take place in cases in which the intelligence of the patient had 
been very much disordered, while of those who, " during the first fifteen 
days of scarlatina, were taken with convulsions, convulsive movements, 
contractions, in a word, any symptoms affecting the locomotive apparatus, 
all without exception, died/' This does not accord exactly with my own 
experience, though nearly enough to show how exceedingly dangerous 
are the symptoms just enumerated when they occur early in the disease. 
General convulsions occurred on the first day of the disease in 7 of the 
41 grave cases observed by myself, and of these not one terminated for- 
tunately ; in one they occurred on the second day, and the patient finally 
recovered; in one they occurred on the ninth day, and this patient also 
recovered; in another case, there were no general convulsions, but on the 
first day there were automatic motions, with involuntary extensor motions 
of the arms and fingers, and on the second day strabismus, with a con- 
tinuation of the automatic motions. This case proved fatal. Of the 10 
cases, therefore, in which marked disturbances of the muscular system 
occurred, only 2 ended favorably. Of 8 subjects in which the convulsive 
phenomena occurred on the first day of the disease not one escaped. Of 
the two recoveries, one occurred in a boy seven years old, who had a 
general convulsion, lasting several minutes, on the second day of the 
attack; this was followed by delirium and coma alternately, but no return 
of the convulsions. The case was a most violent one, and lasted six weeks, 
leaving the child at the termination very deaf, but otherwise in good 
health. The other instance occurred in a child five months old. The 
convulsive symptoms appeared on the ninth day, and consisted of strabis- 
mus, spasmodic retraction of the head, and occasional slight spasms of the 
limbs. They alternated with coma, and disappeared on the tenth day, until 
the seventeenth and eighteenth, when the strabismus reappeared. The 
child recovered perfectly. Again, in 17 of the 41 grave cases, severe and 
more or less prolonged delirium or coma occurred, and of these 11 died. 
We may conclude, therefore, that convulsive symptoms appearing early 
in scarlet fever indicate an almost certainly fatal termination; while 
severe, and especially prolonged delirium or coma, are also extremely un- 
favorable symptoms, but somewhat less so than are those of a convulsive 
character. 

Other unfavorable symptoms are : extremely frequent or very violent 
pulse ; intense heat or unnatural coolness of the skin ; deficiency or sud- 
den disappearance of the eruption ; a livid or purple tint of the eruption ; 
slow and imperfect capillary circulation, as ascertained by pressure; the ap- 



TREATMENT. 519 

pearance of petechise, ecchymoses, or hemorrhages ; violent vomiting and 
colliquative diarrhoea; great violence of the throat-affection, whether from 
tumefaction, great abundance of pseudo-membranous exudation, or dispo- 
sition to ulceration and sloughing ; and lastly, severe coryza or otorrhoea. 
A disposition to a typhoid state, indicated by dulness of the intelli- 
gence, dusky hue of the skin, frequent and feeble pulse, dry, brown 
tongue, sordes on the teeth, meteorism, and disposition to diarrhoea, is 
always dangerous. 

When, on the contrary, the fever is moderate, the cerebral symptoms 
absent or very slight, and the eruption regular, and of a bright tint ; when 
there is no disposition to typhoid symptoms ; when the throat-affection is 
mild, and the disease pursues a regular, uniform course, we have every 
reason to expect a favorable termination in a large majority of the 
cases. 

Treatment. — Hygienic treatment. — In all cases of the disease, whe- 
ther of the mild or grave kind, the strictest attention should be paid to 
the hygienic condition of the patient. The room in which the child is 
placed ought to be, if possible, large, and at all events well ventilated. 
The temperature in winter should be carefully attended to. I usually 
direct it to be kept at from 68° to 70° F., during the early stages of the 
disease, unless the fever is violent, and the child complains of heat, in 
which case it may be allowed to fall to 66°, or even 62°. The clothing 
ought to be moderate, not enough to increase the heat of the skin and 
keep up constant perspiration, nor yet so little as to endanger chilliness. 
During the latter stages of the disease, when the fever has subsided, and 
particularly when the heat of the skin has fallen, the temperature of the 
chamber ought to be kept, as a general rule, at from 68° to 70°, and, 
when the child is pale, weak, and chilly, it may be maintained with great 
propriety, at 72°. 

One of the most important points in the treatment of scarlet fever is, 
undoubtedly, the management of the patient during the convalescence, 
and especially during the desquamative period. It is during this 
period that the child is liable, as we have already shown in our 
account of the different complications and sequelae of the disease, to 
dropsy, which is the most frequent, and at the same time, the most 
dangerous accident to which the patient is exposed. There can be no 
doubt, I think, from the opinions expressed by various writers, and also 
from my own experience, that the most common cause of this accident is 
exposure to cold. Chilling of the body, no matter how produced, is ex- 
ceedingly apt, when it occurs within three, or, more rarely four weeks 
from the invasion of scarlet fever, to be followed by a more or less marked 
attack of some form of dropsy. It is true, I am well aware, that drop- 



520 SCARLET FEVER. 

sical effusions sometimes take place in subjects who have been guarded in 
the most careful possible manner, in whom there has been no evident ex- 
posure to cold ; but it is also true, that a much larger number of those 
who have been thus guarded, escape, than of those who are not thus taken 
care of. I have therefore, no doubt whatever, that it is most wise and 
prudent to confine the patient to well warmed rooms, or at least to the 
house, for twenty-one or twenty-eight days from the outset of the disease. 
The fact that the attack has been a slight one only makes it the more ne- 
cessary to carry out this regulation, as it has been found by experience 
that the dropsy occurs more frequently after mild than after severe attacks. 
M. Legendre (Reclierches Anat.-Pathol. p. 311) is of opinion that the 
patient ought not to be allowed to leave the house until the skin, com- 
pletely deprived of the old epidermis, shall have regained its suppleness, 
its smooth and polished appearance, and all its functions. When, there- 
fore, after a mild case, the desquamation is completely terminated in three 
weeks, the patient, he thinks, may be allowed to go out. But, on the 
contrary, this period would be too short by one-half, if the eruption has 
been very intense, as the desquamation is, in such cases, scarcely finished 
on the hands and feet at that time. 

The diet should consist in the early stage, as a general rule, of weak 
milk and water with or without bread, according to the severity of the 
case, and the state of the stomach. If the fever be very severe, 
barley-water, or arrow-root prepared with water alone, may be given. 
Nothing more substantial than these articles ought to be permitted, in 
most cases, until after the patient is decidedly convalescent, when broth 
with rice boiled in it, or plain boiled rice, and then some light meat in 
small quantity, may be allowed, until the child gradually resumes its old 
habits. When, however, the case runs on for a length of time, or symp- 
toms of prostration come on, light chicken or mutton water may be given 
at once, and small quantities of wine whey, or weak milk punch added, 
according to the degree of the symptoms. 

Treatment of Mild Cases. — A large majority of these cases, need but 
very simple treatment. Some laxative, as magnesia, castor oil, or syrup 
of rhubarb, in such dose as to produce two or three stools, may commence 
the treatment ; or, if the general symptoms be rather more severe than 
usual, an emetic of ipecacuanha had better precede the cathartic. After 
this, a diaphoretic may be given every two or four hours. If the skin is 
very hot and dry, I prefer the antimonial wine and sweet spts. of nitre, 
in the dose of two to four drops of the former, with eight or ten of the 
latter ; or a teaspoonful of neutral mixture, with a little nitre, or the spts. 
mindereri, may be substituted. At the same time a bath should be ad- 
ministered. This may be either a common bath at a moderate tempera- 



TREATMENT OF MILD CASES. 521 

ture (94° to 96°), or an affusion bath, given in the following manner. 
Prepare a bucketful of warm water (96° to 98°) containing from half a 
pint to a pint of vinegar ; undress the child, and place it standing in a 
large tub, with its head and shoulders bent slightly forwards ; then pour 
the vinegar and water from a pitcher over the body, letting it fall from 
a height of two or three feet, in a small, steady stream, on the nucha, so 
that it shall run over the whole surface, and fall into the tub. The mo- 
ment the bath is finished, wrap the child in a warm cotton sheet, over 
which should be put a light blanket, and lay it in bed, or hold it on the 
lap for twenty minutes, or longer, if perspiration is induced, after which 
it is to be wiped dry and dressed. If the fever be violent and accom- 
panied with great dryness of the skin, two bucketsful of water may be 
used. This bath is often followed by copious perspiration and sound, re- 
freshing sleep, with great diminution of the heat and restlessness. It 
may be repeated every three or four hours, if necessary. If the case be 
so mild as not to require an immersion bath, a foot-bath may be used 
with great benefit, as a sedative and diaphoretic. A moderate dose of 
some mild cathartic, or an enema, should be used from time to time, 
through the course of the disease, if the bowels are not moved spontane- 
ously. This simple treatment will, I believe, carry a large majority of 
the mild cases to a safe termination. Sometimes, however, even while the 
disease pursues a regular, uniform course, the general or local symptoms 
assume a degree of activity which renders more energetic treatment ne- 
cessary. 

The febrile movement may be unusually active, and attended with so 
much restlessness, or by such an amount of delirium at night, as to 
threaten a change into the grave form of the malady. When this is the 
case, it is proper to resort to depletion, unless there be some strongly 
contraindicating circumstances present. We may judge of the propriety 
of the measure by the constitution of the child, the state of the circula- 
tion, and the character of the eruption. If the child be not very delicate, 
if the pulse be full and not excessively frequent, if the eruption be neither 
dark nor livid, showing a slow and languid capillary circulation, a vene- 
section of from three to six ounces may be safely and usefully practised, 
and even repeated in twelve hours, if necessary. In cases in which there 
has been unusual restlessness, with violent complaints of headache, in older 
children, without very great fever, I have resorted to applications of 
leeches to the temples with much benefit. At the same time a somewhat 
active cathartic may be given. It is necessary to be careful in the use of 
purgatives; for it must be improper and unsafe to give those which are 
irritating, or such doses of others as might prove so, in a disease which in 
its severe forms, shows a strong disposition to choleratic states of the bowels. 



522 SCARLET FEVER. 

I would rather, therefore, give a medium dose of a laxative remedy, 
and repeat it from time to time, than run the risk of exciting by a single 
overdose, a condition of irritation which could scarcely fail to do mischief, 
by interfering with the regular course of the malady. For these reasons 
I generally resort to magnesia, followed by lemonade; to castor oil in 
orange juice, in the dose of a dessert-spoonful for children over three years 
of age, and a teaspoonful under that age ; to simple syrup of rhubarb in 
the dose of a dessert or tablespoonful ; to a teaspoonful of salts ; or some 
similar remedy, giving directions that the dose shall be repeated in six 
hours, or assisted by an enema, if it fail to operate. At the same time 
the affusion bath as above directed, or the tepid immersion bath, ought to 
be used several times in the twenty-four hours, according to its effects, 
the temperature of the body, and the degree of restlessness. 

The angina needs no treatment whatever in a large majority of these 
cases. The physician should never, however, neglect to examine the 
fauces, when the case assumes any degree of severity. If, under these 
circumstances, he finds evidence of severe inflammation of those parts, in 
the form of swelling, bright or deep redness, and yet more, patches of 
whitish exudation, he may fairly presume that this assists to occasion 
the unusual severity of the general symptoms, and he should immediately 
apply remedies to check or modify the local disease. These may consist, 
under the restrictions already mentioned, of a moderate venesection, fol- 
lowed or not by an application of leeches to the throat; or, if the local 
symptoms predominate over the general, and in very young children, of 
leeches alone. The number of leeches must depend of course upon the 
constitution and age of the child, and the size of the leeches. I generally 
direct from two to three ounces of blood to be taken from a child two 
years old, and from three to five from those who are older. A great many 
different local remedies are recommended by different authorities. Those 
which I make use of are the following : a solution of nitrate of silver (10 
to 20 grs. to the ounce), to be applied twice or three times a day ; pow- 
dered alum used in the same way ; and a solution of sulphate of copper 
and quinine (6 grains of each to an ounce of rose-water), which has been 
very much used and greatly depended upon by my father, and which I 
have found very beneficial. This is to be applied in the same manner as 
the solution of nitrate of silver. With one of these I have always suc- 
ceeded very well in this class of cases. Rilliet and Barthez recommend 
the following preparation : 

R. Acid. Muriat., , . . gi vel gii. 

Mel. Rosse, ^i. — M. 

It is proper to avoid, under the circumstances above described, the use 
of caustic applications, as they are not needed, and as they might aggravate 
the local disease. 



TREATMENT OF MILD CASES. 523 

Within the last few years inunction has been highly recommended in the 
treatment of scarlet fever. It was first proposed and strongly urged I believe 
upon the profession, by Dr. Schneeman, a German physician. Dr. Schnee- 
man makes use of bacon fat. He takes a piece about as large as the hand, still 
covered with its rind, in order to obtain a firm grasp upon it. On the 
soft side of the piece, slits are made in various directions, in order to allow 
the oozing out of the fat. The patient is to be rubbed with this, as soon 
as we are aware of the nature of the case, from head to foot, excepting the 
face and scalp, every morning and evening. The rubbing is to be so per- 
formed, that the skin may be regularly but not too quickly saturated with 
the fat. During the process, only that part being rubbed is to be uncovered, 
or the whole can be done under the bed-clothes (Ranking 's Abst. No. 12, 
p. 26). 

For my own part, I have never made use of the bacon fat for the 
purpose of inunction, except in two instances, being deterred by its dis- 
agreeable character. I have, however, employed inunction with other unc- 
tuous substances very frequently. Indeed, for the last three years, I 
make use of it habitually, in all my cases. The ointment that I prefer 
is the following. I have tried others, but find this one the most agreeable 
and most convenient. 

R. Glycerinee, gi. 

Ungt. Aq. Rosse, ^i. — M. 

There can be no doubt, at the present time, that the employment of 
inunction in scarlet fever has proved a most useful addition to our 
former means of treatment. In my hands it has had the effect of allay- 
ing, in all cases, the violent irritation caused by the intense heat and in- 
flammation of the skin. In nearly all cases, it sensibly diminishes the 
frequency of the pulse, and in many, this effect is very strongly marked. 
It removes, of course, the dryness and harshness of the skin, keeping it 
instead, soft and moist. It lessens, or even removes, the burning, irrita- 
tion, and itching, caused by the eruption. By these effects, to wit, lowering 
of the pulse, and alleviation of the external heat, dryness, itching, and irrita- 
tion, it cannot but, and evidently does modify and diminish, most happily, the 
injurious effects of the disease upon the constitution at large. So great is 
the comfort it gives to the patient, that I have several times had young 
children, still untaught to speak, to make signs and motions, at shorter or 
longer intervals, showing their desire to have the application renewed. 
The frequency of the application must depend upon the case. When the 
eruption is intense, the skin very hot, and the febrile symptoms marked, 
they should be made every three or four hours, or even oftener. In milder 
cases they need to be repeated only three or four times in the twenty-four 
hours. 

Treatment of grave cases. — Bloodlettiny . — The propriety of bloodletting 



524 SCARLET FEVER. 

in grave cases of the disease is questioned by many able observers, while 
others recommend it highly as an efficient means of controlling the dan- 
gerous symptoms. Guersant and Blache {Loc. cit. p. 177) state that in 
the ataxic malignant form " it is rarely useful to take blood, unless the 
general reaction is very acute;" and in another place they say that in the 
adynamic typhoid form, bleeding has never seemed to them to be of any 
use. Dr. Burrows {Libr. Pract. Med. vol. i. p. 365) states that Dr. 
Williams has drawn up a table of different epidemics of scarlet fever 
which have prevailed from 1763 to 1834. Dr. W. says, "the conclusion 
which inevitably follows is, that the chances of recovery are diminished 
by the practice of bleeding, in the ratio of nearly four to one, as compared 
with the chances, supposing the patient not to have been bled." Dr. 
Burrows says, speaking of the anginose form, that in particular epidemics, 
or in some cases, bleeding may be required, but that in general the state 
of the circulation will not bear bleeding. Under the head of scarlatina 
maligna, he says: "If bloodletting from the arm be a remedy of doubtful 
propriety in the former two varieties, it is here hazardous in the extreme. 
At the very onset of the disease the condition of the throat, or fierce deli- 
rium, may require the application of a few leeches beneath the jaw, or the 
abstraction of a few ounces of blood by cupping from the back of the 
neck." Dr. Gr. B. Wood {Pract of Med. vol. i. p. 406) observes, that 
he has " seldom found it advisable to bleed in any case ; and I do not re- 
member the instance in which it appears to me that I had occasion to re- 
pent my abstinence." Dr. Caspar Morris, of this city, in his excellent 
lectures on scarlet fever (Philad. 1851, p. 67), states that, in cases 
in which there is violent delirium, with great heat of skin, very rapid 
pulse, and extreme restlessness, and not unfrequently convulsions, or at the 
least violent muscular twitching, bleeding, whether local or general, is 
"almost always followed by fatal results." Rilliet and Barthez recom- 
mend a bleeding in the early stage of the anginose form, to be followed 
by an application of leeches in robust but not in delicate children. In the 
malignant form with cerebral symptoms, they recommend a bleeding, if 
possible. M. G-ueretin {Loc. cit. p. 301) says, speaking of malignant cases, 
that the most energetic antiphlogistic treatment did not manifestly arrest 
the progress of the violent febrile phenomena, and that in robust subjects 
leeches to the neck and mastoid processes, did not sensibly ameliorate the 
cerebral congestion and delirium. Dr. Eberle follows Armstrong in recom- 
mending active bloodletting in the early period of the malignant form, 
but adds that it must only be during that period, " for the approach of 
collapse renders bloodletting utterly inadmissible." 

Trousseau and Pidoux {Trait, de Therapeutique, t. i. p. 591, 597), 
strongly oppose bloodletting in scarlet fever, except in some very rare 



TREATMENT OP GRAVE CASES. 525 

cases, in which there is u a state of general turgescence, cerebral conges- 
tion, painful tumefaction with stiffness of the articulations, rather elevated 
pulse, vomiting, imperfect generalization of the eruption." At page 596 
are the following words, " of all the eruptive fevers, scarlatina supports 
antiphlogistic treatment least well." 

It ought to be recollected in the consideration of the propriety of blood- 
letting, that the cerebral symptoms which make their appearance in the 
early part of the disease, even during the first two weeks, are rarely 
dependent on inflammatory processes going on in the brain. This has 
been already shown in our remarks upon the cerebral symptoms. I will 
merely repeat here, that MM. Rilliet and Barthez state that a more or 
less active sanguine congestion is the only alteration generally, but not 
always, found in fatal cases, and that in some instances this congestion is 
not greater than what is met with in several diseases unaccompanied by 
cerebral symptoms. Are not these symptoms very analogous to those 
which occur in typhoid fever, and which, according to Louis, cannot be 
shown to depend on any appreciable lesion of the brain ? It seems to me 
that this class of symptoms is dependent upon the state of the blood, 
which, being diseased or poisoned, fails to carry on healthfully the func- 
tions of the nervous centres. If this supposition be correct, what good 
can arise from a treatment which only takes from the circulating channels 
a small quantity of fluid, leaving behind a remainder just as irritating and 
unfit for carrying on the functions of the economy as that which has been 
removed. 

On the whole, it is clear, I think, that the weight of evidence is against 
the use of bloodletting to any considerable extent in grave cases. It was 
the custom in this city, some eleven years since, to make frequent use of 
depletion in this disease, and I saw, therefore, a number of cases treated 
in that way. For my own part, I am convinced from what I then saw, 
that depletion, unless it be employed only as a local means, and even 
then with great care, is much more apt to do harm than good in grave 
cases. It increased, according to my experience, the frequency of the 
pulse ; it had no effect in diminishing the heat of the skin ; the ner- 
vous symptoms, the delirium or stupor, and the convulsive phenomena, 
grew worse rapidly, under its use ; in fact the whole aspect of the case, 
instead of improving under the loss of blood, appeared to me to become 
more and more unfavorable with every repetition of the remedy. Most 
assuredly, I have never seen it produce any of the evidently favorable 
effects which follow its employment in the phlegmasia, or in sudden deter- 
minations of blood to the brain. In mild cases, on the contrary, in which 
the patient suffers greatly from the violence of the febrile reaction, and from 
the enormous development of heat, or in which there is great pain in the 
head or other severe local symptoms, depletion, either topically or by vene- 



526 SCARLET FEVER. 

section, is sometimes admissible, but, even in these cases, it ought to be 
made use of with great prudence and circumspection. 

Of late years, there has been, I think, a growing disposition in this 
city, against the use of bloodletting, most practitioners with whom I have 
spoken having abandoned it in great measure, at least in grave cases. 
This may be owing in part, and indeed it probably is, to the fact that 
the epidemics that have prevailed during the last twelve or thirteen years, 
have been of a severe and dangerous character. 

My personal experience in regard to depletion in scarlet fever has been 
the following. I have known general depletion to prove useful in seven 
mild cases, in which there was a tendency towards the grave form, as 
shown by the presence of excessive reaction, and still more by great jacti- 
tation and irritability, alternating with drowsiness and delirium. But, 
in those sudden attacks of the disease, in which it assumes from the very 
start, the terrible symptoms which threaten extreme danger to the 
patient ; in which we find the child within a few hours of the onset de- 
lirious or comatose, or laboring under convulsions, convulsive movements, 
or contractions ; in which the eruption is imperfect or scanty, or copious 
and of a deep livid tint; in which, in other words, there are either 
strongly marked ataxic or adynamic symptoms, general bloodletting has 
never seemed to me at all advantageous, and I have several times thought 
it very injurious. As to leeches, I have never known them to be really 
useful except in one case, and in that they were used very sparingly, and 
after an interval of two days. In all the other cases they appeared to be 
without any effect. Depletion was made use of in 10 of the 41 grave cases 
that have been under my charge. In 4 of the 10 venesection was per- 
formed once ; in three it was performed twice, and in one of these leeches 
also were applied ; in two leeches were applied once, and in two twice. 
Of the 10 cases, 7 proved fatal. Of the three recoveries, one occurred 
in a patient who was bled once, one in a subject who was leeched once, 
and the third in one who was leeched twice. 

Purgatives ought to be used with care, and only in such doses as to 
secure a soluble state of the bowels, and never to cause violent diarrhoea. 
At the onset of severe cases, attended with prostration and malignant 
symptoms, in particular, the exhibition of large doses of active cathartics 
ought to be carefully avoided. It cannot but be injurious to perturbate 
violently so important a system as the digestive, and through it the 
nervous system, in a disease like scarlet fever, in which nature is about 
to throw out an intense eruption upon the skin, and in which there is 
already only too much disposition towards disorders of the nervous actions 
of the body. M. Gueretin however, recommends, as the only treatment 
that he has found to be really useful in the malignant form, small doses 



TREATMENT OF GRAVE CASES. 527 

of purgatives repeated two, three, or four times a day, so as to produce 
from two to four stools a day. If the stools became more frequent he 
suspended the purgative. This treatment was continued until the febrile 
symptoms had ceased. The remedy he preferred was calomel with jalap 
in doses proportioned to the age of the child. This is the practice also of 
M. Bretonneau. 

Emetics are highly recommended by various writers in the earl} stage 
of the disease. Dr. Eberle (Dis. of Children, p. 461) says, "If called 
sufficiently early, these should always be our first remedies." I have 
prescribed them in several cases, and have certainly thought them useful 
in the regular form, but must confess that like all other remedies that I 
have used, they seemed to exert but little influence over the grave forms. 
In young children, in whom large collections of viscid secretions in the 
fauces occasion difficult respiration, an emetic of ipecacuhana is often ser- 
viceable in mitigating that symptom. 

The antiseptic preparations of soda have been lauded by some persons 
as useful in the treatment of the malignant forms. I have not, however, 
met with any satisfactory evidence in their favor. I have used them in 
several instances, but as it has always been in conjunction with other 
means and particularly with stimulants, it was difficult to determine what 
effect to ascribe to the soda preparations, and what to the stimulants. My 
own impression is, however, that they exert but a feeble influence in a 
grave case of the disease, and that they ought to give place to more im- 
portant remedies, and particularly to the external use of water, inunction, 
and stimulants. 

Chlorate of jpotash has been recommended of late years by several 
authorities, and by some with high commendation. Dr. TTatson dis- 
solves a drachm of the salt in a pint of water, and gives it as a drink to the 
patient. I have made use of this remedy in several cases, and am of 
opinion that it was decidedly beneficial in some in which the throat and 
mouth were very much inflamed and disposed to ulceration. 

Inunction, employed as described in my remarks upon the treatment of 
mild cases, will be found of great service whenever the skin is very hot 
and dry, and particularly when the eruption is intense and accompanied 
with violent itching and irritation. 

Baths ; lotions ; affusions. — I am disposed to believe that, on the whole, 
we derive more useful effects in grave cases of scarlet fever, from the 
judicious external employment of water, than from any other means of 
treatment. The particular mode in which it is to be made use of must 
depend on the character of each individual case. In some the warm, in 
others, the cold bath ; cool, cold or tepid, lotions; or affusions with water 
at various temperatures, must be applied according to the nature of the 



528 SCARLET FEVER. 

ease. I shall refer first to the opinions of different authorities upon this 
subject, and then give the results of my own experience in the matter. 

The warm bath is recommended when the cutaneous action is slow and 
imperfect, the pulse rapid and small, and the nervous actions slow or 
irregular, or in other words, in cases of an asthenic type, in which the dis- 
ease assumes a low and typhoid disposition. 

Lotions, by sponging with water at different temperatures, are highly 
recommended by many authors, and often afford the best means of modify- 
ing the condition of the cutaneous surface. They are most useful when 
the skin is intensly hot and dry, and should then be employed at a tem- 
perature of from 75° to 90° or 92°, according to the degree of the 
cutaneous heat, and according also to their effects at the moment. They 
are to be continued for several moments, or for half an hour even, until 
the heat is reduced and the restlessness of the patient moderated. To be 
of any service they must be repeated as soon as the temperature of the 
skin rises again after it has been reduced by previous sponging. Usually 
it is necessary to resort to them every hour or two hoprs, or even more 
frequently. It is scarcely needful to say that cool or cold lotions are to 
be used only when the reaction is strong and well-marked, and not when 
the skin is pale and cool, and the pulse feeble and rapid. Under those 
latter circumstances, lotions with warm or hot water, or warm or hot 
baths, in connexion with internal stimuli, would be the proper remedies. 

We come now to the consideration of another method of treatment, 
which has been asserted to be most efficient in the violent forms of the 
disease by several persons of high authority in medicine, while by others 
it is considered dangerous and improper. I refer to the use of affusions 
with cold water. The treatment was particularly relied on by Dr. J. 
Currie of Edinburgh. Let it be observed, however, that Dr. Currie limits 
its use to cases to which he applies the term anginose, many of which, I 
doubt not from his description, ought to be classed as mild cases. He 
mentions another class of cases which he thinks ought rather to be called 
"purpurata," characterized by "extreme feebleness and rapidity of the 

pulse, and great fetor of the breath The heat does not rise 

much above the standard of health. Great debility, oppression, headache, 
pain in the back, vomiting, and sometimes purging, accompany its rapid 
progress; the patient sinks into the low delirium, and expires on the 

second, third, or fourth day The cold affusion is scarcely 

applicable to it, and the tepid affusion makes little impression upon it. In 
my experience, indeed, all remedies have been equally unsuccessful. It 
outstrips in rapidity, and it equals in fatality, the purple confluent small- 
pox, to which it may be compared." (Currie' s Med. Reports, Philad. p. 
277.) It is clear, therefore, that Dr. Currie, when he speaks of nearly 



TREATMENT OF GRAVE CASES. 529 

invariable success in upwards of one hundred and fifty cases (p. 286), had to 
do, not with the malignant, or at least, not with the most malignant forms, for 
which we are seeking a remedy, but with cases of a mild form, or at most with 
those of the severe anginose type. Indeed, at page 294, we find the following 
remarks. " It has come to my knowledge, that in two cases of scarlatina, of 
the most malignant nature, the patients have been taken out of bed, under 
the low delirium, with the skin cool and moist, and the pulse scarcely per- 
ceptible. In this state, supported by the attendants, several gallons of per- 
fectly cold water were madly poured over them, on the supposed authority of 
this work ! I need scarcely add that the effects were almost immediately 
fatal." I have been induced to enter thus much into detail, in regard to 
the use of cold affusions, because of the intrinsic importance of the subject, 
and because of the remarks upon it in the work of MM. Eilliet and 
Barthez, who bring forward Currie's success, as a strong argument in 
favor of their employment, in that form of the disease in which cerebral 
symptoms predominate. Currie does not recommend them, however, 
except in cases in which the reaction is full and strong, as indicated by 
very great heat of skin, scarlet eruption, and rapid, but not feeble pulse. 
In the famous cases of his own two children, it is evident that the attacks 
were not malignant, for the skin was very hot (108° and 109° F.), and no 
mention is made either of stupor or delirium, much less of convulsive 
phenomena. Dr. Geo. Gregory, of London, whose opinions in all matters 
connected with the eruptive fevers, are of course, worthy of great weight, 
says {Led. on the Eruptive Fevers, edited by Dr. Bulkley, New York, p. 
190), in relation to the use of cold affusions; " Sanctioned by my uncle, 
the late Dr. Gregory of Edinburgh, this plan has been amply tried in all 
parts of the world, but it has not realized the expectations of its proposer. 

" The truth is that the cold affusion is applicable only to a small number 
of cases. It is adapted for young people with high anginose inflammation 
and a burning hot skin, without plethora, without depression of nervous 
energy; but it is inapplicable to the scarlatina of adults, accompanied with 
coma, phrenitis, or marked debility. It is wholly unfit for cases of cynan- 
che maligna. It answers its purpose very well for the first day or two, 
but it is often impossible to continue its use. Lastly, it seems to increase 
the disposition to dropsy." 

The evidence brought forward by Currie, Gregory of Edinburgh, and 
Billiet and Barthez, in favor of the eflicacy of cold affusions in the treat- 
ment of severe cases of the disease, is such, however, as ought to call 
attention to this point, though my own impression is that lotions with cool 
or cold water are safer, more agreeable to the patient, more convenient in 
every respect, and quite as useful, as cold affusions. If employed at 
all, they ought evidently to be restricted to cases, in which the reaction is 

34 



530 



CARLET FEVER. 



perfectly well marked, in which the skin is hot and dry, the pulse, though 
frequent (150 or 160), strong, and the eruption not of too dark a tint. 
The child is to be undressed, and placed erect or sitting in a tub, while 
four or five gallons of water, at from 60° to 70° F., are poured over the 
head and body. The good effects of the remedy are said to be an imme- 
diate reduction of the heat, a diminution in the rapidity of the pulse, 
which in one of Dr. Gregory's children fell in half an hour after the cold 
affusion from 160 to 120, a disposition to sleep and quiet, and, according 
to Dr. Gregory, a seeming arrest of the throat- affection. These good 
effects of the affusions are transient, however, as the heat of skin, and 
rapidity of the circulation, return in the course of one or two hours. For 
tthis reason it is necessary to repeat them frequently, once in two or three 
hours at least, in order to render the effects permanent. Currie used 
fourteen affusions for one of his own children, and twelve for another, in 
thirty-two hours. These were not, however, all cold. Gregory used for 
his child five "good sousings/' to use his own words, in twenty-four 
hours. 

MM. Billiet and Barthez give in the following words the conclusions 
of Henke in regard to the use of cold affusions: 1. Cold affusions are 
not adapted for a general method of treatment. 2. The slight, or simply 
inflammatory forms, do not at all demand so energetic a treatment. 3. 
Their employment must be reserved for cases in which the disease is epi- 
demic, and accompanied by intense heat and dryness of the skin, with 
smallness and acceleration of the pulse, and for those in which the cerebral 
symptoms are very violent and characterized by great restlessness, alter- 
nating with drowsiness, commencing from an early period of the disease. 
Scarlet fever, under these circumstances, is so dangerous, they say, and 
so often mortal, that recourse ought to be had to all curative means, and 
in children the cold affusions are much more strongly indicated than 
bleeding. {Loc. cit. vol. ii. p. 653.) 

Believing that evidence of the effects of any plan of treatment in 
grave cases of scarlet fever, must be acceptable to all who feel an interest 
in the progress of medicine, I insert at this place an account of the 
employment of cold lotions, by Dr. Hiram Corson, of Conshohocken, 
Montgomery County, Pennsylvania. The cases narrated occurred in his 
own practice, and were kindly communicated by letter, at my request. 
Dr. Corson wrote to me as follows, in July, 1847 : 

" Dear Doctor, 

" Scarlet fever is a disease that has prevailed very much in our region 
during the last seventeen years, and has caused me much thought and 
anxiety. It will give me great pleasure to make you acquainted with 



TREATMENT OF GRAVE CASES. 531 

the results of a plan of treatment, which I owe mainly to Doctor Samuel 
Jackson, formerly of Northumberland, now of your city, who first put me 
in the way of treating the disease successfully. In 1833, I treated the 
disease, which, however, was not malignant, very successfully, with iced 
drinks, moderate purges, and slight irritation externally upon the throat, 
and thought the practice peculiar to myself, but afterwards saw in the May 
and August numbers of the Am. Journ. of Med. Sciences, the communi- 
cations of Dr. Jackson. Encouraged by these, I prepared to try the cold 
externally, when a most unfortunate trial, by a neighboring physician, so 
alarmed the people about the application of cold, that I could not prevail 
upon them to suffer the trial. From 1838, until within the last two 
years, we have annually had the scarlet fever for some months, and my 
treatment with the exception of iced drinks sometimes, and cold to the 
head occasionally, was like that in general use, until August, 1844. At 
that time I was called to a child eight months old, who had been sick two 
days. There was great swelling of the glands of both sides of the neck, 
hot skin, frequent pulse, but no eruption ; slight discharge from the nose ; 
the glands not easily seen upon the inside, but the drinks came back 
through the nose sometimes, and it could not take more than one draw 
at the breast, without dropping the nipple, because of the obstruction in 
the nostrils impeding respiration when the mouth was closed. I stated 
candidly to the mother that I had never saved a child in that condition, 
and of that age, by the old treatment, and recommended ice externally and 
internally, cold water to the head, and no medicine. I could urge nothing 
upon the score of experience, but she agreed. Lumps of ice were folded 
in linen cloths and held night and day upon the two sides of the throat ; 
while a small thin piece enclosed in white gauze was held in the mouth. 
In less than three hours improvement was manifest in the ability to 
swallow. The swelling of the glands, the heat, and the frequency of the 
pulse all regularly diminished, and in two days the child could nurse well 
and was out of danger. 

u The next severe case occurred in about two weeks. It was one of the 
most intense scarlet eruption, with tumefaction and ulceration of the ton- 
sils, vomiting, coryza, great frequency of the pulse, excessive restlessness, 
and swelling of the external glands. The heat was intense ; there was 
heaviness amounting almost to stupor. My treatment was a kind of half 
and half: emetics, purgatives, cold externally and internally. Being but 
half satisfied with myself, my course was vacillating, and inefficient, and 
I at length called in a friend, who turned the scale in favor of irritating 
gargles, and our patient died. I was mortified and provoked, and deter- 
mined to act out my convictions at the next opportunity. A few days 
after I was called to two boys of five and seven years of age, who had been 



532 SCARLET FEVER. 

blistered upon the throat, legs and arms, and had had hot drinks, calomel 
purges, etc., etc., and who were discharging copiously from the nose, and, 
were almost deaf. Their countenances were sunken, the throats gangre- 
nous, pulse above 150; their appearance was that of persons in typhus 
fever. I expressed my fears of the blisters, predicting that they would 
all be gangrenous in twenty-four hours, and that they would be likely to 
destroy the patients. I had cloths dipped in iced water wrapped round 
the neck, ice was put into the mouth, and cold water poured upon the 
heads, which were much affected. The throats were filled with ropy 
mucus, which was expelled through the mouth and nose during the cough- 
ing which attended efforts to vomit. The palate was literally destroyed 
by gangrene. A few hours produced an amendment. The blisters morti- 
fied extensively, and though both children recovered from the disease, one 
died two weeks afterwards from the sloughing of the throat and neck from 
the blisters. 

" I now treated all the cases that occurred with cold externally and 
internally ; moving the bowels with equal parts of cream of tartar and 
jalap. The cases were seen early and easily subdued, and it seemed to 
me as though the remedy was very efficient, or that my patients had a 
mild disease. That the latter was not the case, however, I thought pro- 
bable from the fact that in my region, many cases differently treated died ; 
while in Norristown, only four miles distant, children from one to twelve 
years or more, were swept off after an illness of only two or three days, 
the deaths being evidently produced by disease of the brain. 

" On the 16th July, 1845, I was called to see a little girl four years 
and nine months old. She had been sick a day or two. The case began 
with vomiting. The eruption has been out since morning (now, 6 P. M.); 
redness the most intense all over that I ever saw ; pulse as rapid as it 
could be to be counted. The mother had been alarmed during the last 
few hours, in consequence of delirium and jerking, which she feared was 
the prelude to convulsions. There was tumefaction of the submaxillary 
ganglions; tongue furred, with projecting red points; breath hot and 
offensive. When she found some one holding her wrist, she started from 
her dozing state, and being somewhat afraid of the i doctor/ went off 
immediately into one of the most terrific convulsions that I ever saw. It 
lasted, in spite of ice to the head, or rather iced water constantly poured 
upon it, almost half an hour. I stayed with her, had her undressed, and 
placed two nieces of mine (her mother being one) by her side. A large 
tub of water with cakes of ice, at least a peck, floating in it, was brought 
into the room, and during the xohole night, these two persons bathed her 
from head to foot with the water from this tub, applying it by means of 
large sponges. It was to me a most painful case (independent of the con- 



* TREATMENT OF GRAVE CASES. 533 

vulsions), but in order to be certain that I had a case fit for a trial of the 
ice, I had my brother (a physician practising at Norristown, where the 
disease was very fatal) brought at 10 P. M., to see the case, and to say 
whether it was the same as those that had for a fe t w weeks been carrying 
off some of the finest children in Norristown, and carrying terror into 
every family. He assured me that it was one of the most violent cha- 
racter, and that she would in all probability not live till morning. She 
was at this time free from convulsions, but in a muttering delirium. As 
I had perfect control in the case, I assured him that she should live if I 
could quench the fire that was burning out her vitals, by the use of ice. 
Not a moment did the attendants whom I had placed by her intermit their 
labors. Before midnight reason had returned, and her mother said she 
was more herself than she had been during the whole day. I had gone 
away, but returned at sunrise, and found her cooled off perfectly. There 
was scarcely the least appearance of eruption, the skin was cool, the head 
cool, the intellect clear, and the pulse moderate in frequency and force. 
She had been unable to drink for many hours, and her tongue, which had 
been very much cut during the convulsion, was so swelled and sore, that 
I could obtain no view of the throat. I now directed the mother to inter- 
mit the sponging, doing it only once in every two hours, until I returned. 
My return was delayed until 4 p. M., when I found that the heat of skin, 
frequency of pulse, eruption, and delirium had all returned. She was 
moving her hands as if feeling for something, slowly protruding and with- 
drawing the tongue, and muttering. She did not notice her mother's 
questions, and was apparently unconscious to all that was going on. "We 
threw on the water, ice-cold, in the utmost profusion, and lapped cloths 
dipped in the water around the neck, changing them every minute or two. 
We poured it upon the head constantly, holding a large basin under to 
catch it. In one hour, reason returned. We continued it until the erup- 
tion almost disappeared, until the child shrank from it, and until she was 
ready to shiver with cold. I now gave her cream of tartar and jalap, 
directed the water to be used just as was needed to keep down the heat, 
and had no farther trouble with her. I forgot to say that so soon as she 
could swallow, cold drinks and ice were kept in the mouth. She took no 
more medicine. The wounds in the tongue healed up kindly. 

" There were two younger children in the family, both of whom were 
attacked a few days after, while apparently in good health, with vomiting 
and the same symptoms as in the first case. The throats were red and 
swelled, etc. Cold cloths were wrapped around the neck; they were 
purged with jalap and cream of tartar; as the heat of skin and eruption 
appeared, ice water was profusely applied to the whole body, so as to keep 
down the heat, and allow but a very moderate eruption to show itself. 



534 SCARLET FEVER. 

They were well in a few days without a bad symptom. It was now mid- 
winter. The cases followed each other rapidly. I treated them all in 
the same way, and all with like happy results. The disease had a wide 
range, extending from the Schuylkill across the highlands between 
Norristown and Doylestown, and was in that range very destructive in 
many families. There was much alarm, and I was called two miles back 
of Norristown to a girl about eleven years old. The eruption had been 
out about twenty-four hours. The throat was swelled and covered with 
white patches (generally called ulcers) ; tongue dry, hot, and red ; skin 
hot as skin could be ; and, what to me characterizes the most malignant 
cases, the eruption instead of being of a bright scarlet, was of a purple red, 
like the congestion sometimes seen in the faces of old drunkards. There 
was great oppression, not difficulty of breathing, but a state like that 
which exists when a person is deathly sick but cannot vomit ; with ex- 
treme restlessness and jactitation. The disease had been so fatal, that, the 
mother thought the case almost beyond remedy, but when I told her that 
the cold had proved successful she was eager to try it. It was 8 o'clock, 
A. M. The girl was stripped, and the ice water applied all over. Ice 
was lapped around the neck, and positive directions given to continue the 
applications without intermission until I returned. It was about four 
miles from me, and I did not return for seven hours. The moment my 
eyes rested upon her, I knew that we had done too much. She was white 
as the sheet upon which she lay. The neighbors had been in and desired 
the mother to desist, that ' she would kill her/ but she had been true to 
her trust. The child was apparently bloodless, covered with ' goose-skin/ 
and shivering with cold. Her pulse was small and much less frequent, 
but not weak or fluttering, and she was sensible. (I forgot to say that in 
the morning she was quite flighty.) I told the mother we had used 
rather more cold than was necessary, but that if we left it off now she 
would probably do well. I omitted it for two hours, and gave nothing. 
At the expiration of that time, the heat, and with it the eruption, showed 
themselves, so as to cause me to direct the sponging to be used just so as 
to keep them in check. The ice was kept constantly to the neck, and 
water frequently poured over the head. I had no more trouble with her, 
although she desquamated from head to foot. 

u Six other children in the family took the disease. Five of them had 
the ice and ice water used upon them, and all did well. I gave none of 
{hem any medicine except a little cream of tartar and jalap, to move the 
bowels moderately. I gave this combination because it is pleasant to 
children, and easily swallowed. The sixth case was a very mild one, so 
that the mother merely gave it a little castor oil, and it did well, and 
seemed perfectly recovered in a few days. Indeed the attack was so mild, 



TREATMENT OF GRAVE CASES. 535 

that it would not have been detected as scarlet fever, if it had occurred at 
any other time. It was attacked with dropsy and an affection of the 
lungs, about two weeks after, lingered for several weeks, and finally died 
of pneumonic disease. 

" I suppose I have attended more than a hundred cases of scarlet fever 
of every grade, since I began the cold treatment. In no instance where 
I had it fairly applied did it fail. Indeed I have lost but two patients 
since. 

"In every variety of sore throat and quinsy, in summer and in winter, 
my treatment is ice around the neck ; or, when the nurse is faithful, iced 
cloths, renewed as soon as they approach the heat of the neck. 

" In no single instance have I seen dropsy follow scarlet fever that 
had been treated by cold affusion. I have never seen it occur except 
after the mildest cases of the disease, those that had probably only needed 
a mild laxative." 

I wrote to Dr. Corson again, in the early part of the present year, 
(1853), for the results of his experience in the same treatment since the 
date of his first letter (July, 1847). Dr. Corson informs me that an epi- 
demic occurred in 1852, during which he had ninety cases, of which ten 
died. Of these, two, he says, died of the sequelae. They were not seen 
by him until one had been laboring for several days under inflammation of 
the pleura, while the other had disease of the heart and dropsy. In 
these two cases, and another fatal one in which the prostration was ex- 
treme, ending fatally a few hours after Dr. Corson had seen it, no cold 
applications were made use of. In most of the other cases also he had 
not the means, he says, owing to the scarcity of ice and cold water, 
of carrying out his treatment. His present opinion in regard to the use 
of cold water is expressed in the following language ; " The result of my 
observations but confirms my former experience in relation to the good 
effects of cold affusions and cold topical applications in this disease ; but 
I confess my great ignorance of the proper application of this remedy. 
It needs much knowledge of the physiological effects of different modes 
of application. Many cases need the continuous application for many 
hours, — such as those where the eruption is vivid, heat great, throat 
swelled, etc. ; while those where the surface is but moderately hot, the 
extremities cool, and in which cerebral symptoms are manifest, cold 
sponging followed by quick and free rubbing with crash, and repeated 
every fifteen or twenty minutes ; or the cold sponging followed by 
wrapping in a blanket so as to produce free perspiration, cold water being 
poured continuously upon the head for hours, with cold applications to 
the throat, would perhaps be the most proper plan. But, I repeat, I am 
not well skilled in the best modes of application, but it seems to me that 



536 



SCARLET FEVER. 



in the hands of an adept, it could be adapted to every condition of the 
disease." 

It appears to me very clear, if I may be allowed to criticise the results 
of Dr. Corson's experience, that the cases which he has seen since his 
first letter have had the effect to lessen somewhat the enthusiastic confi- 
dence in the treatment by cold, which is so strongly expressed in his first 
communication. He still retains great faith in the treatment, but it 
would seem that his results, as detailed in the last communication, have 
not been so favorable as they were before. He has probably had to do 
with a worse epidemic, and has found, as all before him have, that, in 
malignant cases, in which the febrile reaction is imperfect and the symp- 
toms low and typhous in character, cold used indiscriminately is very 
dangerous, and used even in the best and most judicious mode, but too 
often, like everything else thus far discovered, inefficacious against this 
fatal scourge. 

My own experience in the use of cold applications has not been very 
extensive as I have preferred the use of the tepid affusion bath, of 
immersion baths, and of lotions with tepid or cool water. I have never 
employed the cold affusion over the whole body, and never saw it em- 
ployed but once. In that instance, a single bucketful of water at 70° 
was poured over the child, but as it was not repeated, no good effects, 
beyond a very transient reduction of the heat, and quiet for a short time, 
were produced. In another instance I made repeated affusions upon the 
head with water at 70°, pouring at one time seven bucketfuls upon that 
part. This was a case attended with coma, strabismus, and spasmodic 
retraction of the head. In addition to the affusions, cloths dipped into 
iced water, were kept applied the greater part of the time. These means, 
especially the affusions, were evidently advantageous, and the child 
recovered. 

I have made use of lotions with cool water (70° to 72°) in three grave 
cases. In two they were evidently useful j in one they did no good, and 
were perhaps injurious, as I believe now that the case might have- been 
better treated with prolonged warm baths at a temperature of 92° to 95°, 
cold to the head, and internal stimulation. The latter case was one in 
which the patient had two convulsions on the first day, and one on the 
second. The pulse rose at once to between 160 and 170 ; the head and 
trunk were very hot, whilst the extremities were coolish ; the child was 
either excessively dull or comatose. Cloths wet with iced water were kept 
constantly upon the head, and the body, and occasionally the limbs were 
sponged with cold water. The internal remedies consisted of carbonate 
of ammonia and milk-punch. The patient improved decidedly on the 
third day, so that the pulse came down to 152, the intelligence returned, 



TREATMENT OF GRAVE CASES. 537 

though the child was still very drowsy and heavy, and the ease looked 
quite promising. On the fourth and fifth day, the throat-affection came 
on ; the neck and throat swelled enormously, the cervical lymphatic glands 
became very large, the nasal passages discharged streams of offensive 
grumous pus, the ears ran copiously, the fauces became pseudo-membra- 
nous, the deglutition grew worse and worse until at last it was impossible, 
and the child died on the middle of the sixth day, a mass of the most 
disgusting and offensive disease. One of the grave cases in which the 
cool applications proved useful, occurred in a hearty, vigorous girl, twelve 
years of age. On the third day of the attack, the symptoms were as 
follows. The pulse was between 160 and 170, small and quick ; skin 
intensely hot; eruption very copious and of a dark red color, tend- 
ing to* violet ; capillary circulation slow and languid ; tongue black, and 
covered with a hard dry crust; teeth and lips dry, and covered with 
dark incrustations. There was very great agitation and restlessness, with 
constant moaning and complaining, and total insomnia. Under these 
circumstances, I directed the nurse to sponge the head and extremities 
of the patient with water of the temperature of the room (68° to 70°). 
As the water became heated by contact with the skin, small pieces of ice 
were put into the basin so as to keep the temperature at the point men- 
tioned. At the end of four hours, the washing having been continued all 
the time, I found the patient decidedly more comfortable. The pulse 
had fallen to 140, and increased in volume ; the heat of skin was much 
reduced ; the color of the eruption had improved, having become much 
more scarlet in tint ; the capillary circulation was more active ; the agita- 
tion and restlessness had very much moderated, and the child had slept 
somewhat at short intervals. This treatment, in conjunction with the 
internal administration of the solution of chlorinated soda, and small 
doses of spirits of turpentine, was continued for several days, the spong- 
ing being used whenever the heat and restlessness were great, and the 
pulse very rapid. The child convalesced about the end of the third week, 
but was unfortunately seized with symptoms of hydrocephalus on the 
twenty-fifth day, and died in twenty-three hours, after the most frightful 
convulsions I ever saw. 

Without attempting to describe more particularly my experience in 
individual cases, I shall proceed to give a summary of what I believe to 
be the best mode of employing the class of remedies now under considera- 
tion (baths, lotions, and affusions). Of the various means that I have em- 
ployed or seen employed in grave cases, these alone, either singly or in 
connexion with the use of stimulants, have seemed to me to exert a mani- 
festly beneficial influence upon the disease. In cases attended with low 
delirium, stupor, or coma, or with convulsive phenomena, in which the 



538 SCARLET FEVER. 

extremities are cool or coolish, even though the head and trunk may be 
intensely hot, and where the eruption is scanty and imperfect, or copious 
and of a dark and purple tint, the warm bath at 95° or 96°, continued for 
twenty minutes or half an hour, and repeated every two or three hours, 
in connexion with the internal employment of stimulants, as ammonia 
and brandy, and with cold to the head, either by means of wetted cloths, 
or by a prolonged cold douche, afford the best means of treatment that I 
am acquainted with. Under these circumstances, the warm bath has 
always appeared to ameliorate for the time being the condition of the 
patient. From being entirely comatose, or exceedingly heavy or delirious, 
the child has, while in the bath, often awakened from its stupor and 
regained a slight degree of intelligence, so as to open its eyes, look round, 
and drink freely. In cases attended with convulsions, the warm bath, 
with cold cloths to the head, or better still, a prolonged cold douche upon 
the head, will very generally cause the cessation of the convulsive 
symptoms. Unfortunately however, the effects of this treatment are only 
too frequently but transient, for, though the heat of skin has remained 
rather less for some time after the immersion, the coma and sometimes 
the disposition to convulsions have very soon returned. The same state- 
ments are made by M. Gueretin (Loc. cit. p. 302). Nevertheless, these 
means, the frequently repeated warm bath, cold to the head, and internal 
stimulation, offer, I believe, the best means that have as yet been dis- 
covered of treating those malignant cases in which, within a few hours 
from the very moment of invasion, the patient lies before us comatose or 
convulsed, stupid or delirious, with a scanty or dark-colored imperfect 
eruption, with coolish or cold extremities, and with small, feeble, and 
very rapid pulse. 

In cases of scarlet fever not quite so severe as those just now alluded 
to, in which the pulse, though very frequent, remains somewhat full 
and strong, in which the cutaneous heat is very great and properly distri- 
buted, in which, though the patient is heavy and dull, he is not comatose 
nor convulsed, or if convulsed only momentarily so, and that from the 
intensity of the febrile reaction, and in which if delirium exists it is 
slight and of a higher kind than in the previous class of cases, the 
most suitable treatment is the following. The affusion bath of vinegar 
and water, as recommended in my remarks upon the treatment of mild 
cases, should be used every two or three hours, at a temperature of from 
90° to 95° ; after the bath the child should be wrapped in a cotton sheet, 
and placed in bed in a light blanket, for twenty minutes or half an hour ; 
when dry the body should be rubbed all over with the ointment already 
described. The head is to be kept cool by means of wetted cloths. The 
only treatment necessary is a mild laxative, iced drinks, as lemonade, 
orangeade or mineral water, the chlorate of potash solution already spoken 



TREATMENT OF GRAVE CASES. 539 

of, neutral mixture, and sweet spirits of nitre, or spirits of mindererus. 
When, from any cause, as want of the necessary conveniences, or from the 
terror it sometimes inspires in the child, the affusion bath cannot be em- 
ployed, we ought to make use, instead, of tepid or cool spongings and of 
inunction. 

In yet milder cases than those just described, in which, though the 
pulse is frequent, it is quite full and strong, in which the eruption is 
abundant and bright in tint, and the whole cutaneous surface hot and 
dry, and in which the nervous symptoms are not of a very threatening 
character, the only external means necessary to be used, are an occasional 
tepid immersion bath, or better still, a warm affusion bath, or else frequent 
spongings with tepid or coolish water, and frequent inunction. The inter- 
nal means should consist, as in the previous class of cases, of cool and 
refrigerant drinks and simple diaphoretics. 

Tonics and Stimulants. — In certain grave cases of scarlet fever stimu- 
lants are required from the very commencement of the attack, — at least 
such is the opinion of some of the best medical authorities, and such also 
is the conclusion to which experience has brought me. Dr. Gregory, of 
London (Loc. cit. p. 187), in speaking of the cases of " angina maligna 
gangrenosa/' in which the eruption is undeveloped, and which, from the 
onset, are characterized by depression, or collapse of the nervous system, 
says : " Common sense here dictates an early recourse to stimulants, — to wine, 
brandy, cordial draughts containing ether, camphor julep, aromatic con- 
fection, and tincture of bark, in such quantities and doses as the stomach 
will bear, and the age of the patient justify. On this point there is no 
room for cavil or doubt." Dr. Wilson (Dis. of the Skin, Am. Ed. p. 93) 
remarks that the "vast depression of the powers of the nervous system that 
exists in scarlatina maligna indicates a tonic plan of treatment." He 
proposes quinine, with infusion of roses, dilute sulphuric acid, etc. He 
states also that the " tonic and nutritive properties of wine or good beer 
render them invaluable remedies in these cases." Dr. C. Morris, of this 
city (Loc. cit. p. 94), says " the malignant form requires that the first 
symptoms of failure of vital powers should be met by a prompt resort to 
the use of capsicum, quinine, wine, and nourishment." Dr. West (Loc. 
cit. p. 540), in speaking of the use of ammonia almost from the onset of 
the disease, remarks, "It is a practice which has been recommended as 
universally applicable, and which (though the remedy does not deserve 
the indiscriminate encomiums that have been lavished on it) you will do 
well to follow, whenever the pulse presents the characters of great fre- 
quency and softness combined." In cases of scarlet fever, therefore, in 
which, from the beginning, the pulse is small, feeble, and rapid, the cuta- 
neous action imperfect, as shown by a scanty or irregular eruption, or by 



540 



SCARLET FEVER. 



one of a dusky or purple color, in whieh the movement of the blood in the 
capillaries is sluggish, in which the temperature of the body is uneven, 
the extremities being cool, whilst the head and trunk are hot, in which 
the patient is dull, stupid, comatose, or affected with low delirium, and in 
which low nervous symptoms, as irregular muscular movements, automatic 
movements, or subsultus tendinum, are present, it is evidently proper and 
necessary to make use of stimulants and tonics. The stimulant most 
highly recommended in the early stage is carbonate of ammonia : quinine, 
bark, the different acids, wine and brandy, may also be made use of. It 
ought not to be forgotten, however, that while stimuli are being employed, 
the hot, warm, or tepid bath, prolonged for some length of time, and 
repeated every two or three hours, or spongings, with cold to the head by 
means of wetted cloths or by a cold douche, constitute quite as important 
a part of the treatment as the stimulants. 

In slow and tedious cases of the disease, which, perhaps, were of an in- 
flammatory type in the beginning, adynamic symptoms frequently occur 
after the attack has been going on for one or two weeks. The pulse 
becomes frequent and small, the skin cool and moist, or hot and cold by 
turns, the tongue is dry and cracked, sordes collect upon the teeth, and 
there is jactitation, muttering delirium, and various nervous symptoms, 
which all clearly indicate great exhaustion of the vital powers. Under 
these circumstances it is proper to resort to whatever means are likely to 
uphold the constitution, and impart to it strength to resist the slow disease 
which tends to destroy it. With this view the diet ought to consist of 
milk preparations, and of light animal broths, with bread, if the child will 
take them. At the same time wine-whey in proper doses, and at fixed 
periods, ought to be given ; — or the whey may be mixed with arrow-root 
water , — or wine may be given in simple cold water. If the prostration 
is very great, small quantities of brandy may be used. We may resort 
also to the internal use of quinine, in the dose of a grain three or four 
times a day, to a child two or three years old, or to the cold infusion of 
bark. The aromatic spirits of hartshorn is useful in doses of ten or fifteen 
drops every two or three hours ; or the carbonate of ammonia in emulsion ; 
or infusion of serpentaria, which latter is highly spoken of by some of the 
German authors. For my own part, I rely chiefly on diet, wine and 
brandy, and quinine. This treatment should be continued as long as the 
adynamic symptoms last. In a few cases of this kind, I have obtained 
good effects from the use of chlorate of potash, in the dose of two grains, 
to children of three or four years old, every two or three hours. The 
solution of chlorinated soda has also proved useful. I have given from five 
to ten drops of it every two or three hours. 



TREATMENT OF THE ANGINA. 541 

Treatment of the Angina. — The pharyngeal inflammation requires a 
chief share of our attention in all grave cases of the disease. 

It is scarcely necessary, after the previous remarks on bloodletting, to 
say much in regard to its employment in combating this element of the 
malady. It may be used with great caution in the very earliest stages, 
while the reaction is still full and strong. I prefer leeches to bleeding, and 
believe that about four ounces are as much as ought generally to be taken 
from a child three or four years old. In grave cases of a malignant type 
it has been found not only that the loss of blood from leeches is injurious 
to the patient, but that the leech-bites are very apt to inflame badly, to 
ulcerate, and even to become gangrenous, so that they ought never to be 
made use of in such cases. Moreover, the bites often bleed for a length 
of time after the removal of the leeches, the blood oozing out by a process 
of leakage, and rendering it difficult to arrest the hemorrhage. 

When the external swelling is considerable, benefit is sometimes derived 
from the steady application of warm poultices to the part. They should 
be inclosed in portions of thin soft flannel, and secured by means of a 
very light cravat ; they must be renewed every two or three hours. The 
reader's attention is called to the use of cold applications to the throat, as 
recommended by Dr. Corson, in the letter appended to my remarks on 
baths and lotions. In cases attended with great heat of skin and fully 
developed pulse, cold applications to the throat, consisting of pieces of ice 
wrapped in flannel, and applied behind the angles of the jaw, or of cloths 
wetted with iced water, may very properly, and, I believe, advan- 
tageously, be made use of. In one case in which I made use of the cold 
cloths, they were evidently beneficial. A great variety of local remedies 
have been proposed by different authorities. The best of all is, almost 
without a doubt, the nitrate of silver, applied in solution. The strength 
of the solution varies almost indefinitely, some employing a caustic, and 
others a weaker one. Of late years I have generally made use of one of 
twenty grains to the ounce, but many excellent writers assert that one of 
forty, and even sixty grains, to the ounce is better. Powdered alum also, 
and solutions of sulphate of zinc or copper, are very much employed, but 
they cannot, in my opinion, be so entirely depended upon in a bad case 
as the nitrate of silver. 

Cauterization of the throat, with the view of arresting the formation of 
the exudation, so useful and important in primary pseudo-membranous 
pharyngitis, seems to be of doubtful propriety in this disease. G-ueretin 
(Loc. cit. p. 300) is of opinion that cauterization increases the phlogosis, 
augments the tumefaction of the ganglions, and aggravates the fetidity of 
the breath. Cazenave, on the contrary (Abreg. Prat, des Mai de la 
Peau, p. 56), advises the early touching of the diphtheritic patches with 



542 SCARLET FEVER. 

muriatic acid or nitrate of silver, in order to modify the peculiar inflam- 
mation. He also states that M. Biett employed habitually a mixture of 
equal parts of lemon juice and honey. MM. Rilliet and Barthez recom- 
mend an application consisting of equal parts of honey of roses and mu- 
riatic acid. Cayenne pepper in infusion or substance has been recom- 
mended by different authors. Dr. Gr. B. Wood {Loc. cit. vol. i. p. 408), 
thinks that it exercises a peculiar and very happy influence " when the 
pseudo-membranous or gangrenous patches are observed in the fauces, and 
when the color of the mucous membrane is dark red." He mixes the 
powder in water, and applies it to the fauces by means of a large camel's hair 
pencil. When the breath is very fetid, the liq. sodas chlorinatae, diluted 
with eight to ten parts of water, is said to be very serviceable. 

In the use of any of these preparations in children, it is necessary to 
apply them to the fauces in the manner described in the article on idio- 
pathic pseudo-membranous pharyngitis. When viscous secretions collect 
in the fauces in such quantity as to cause serious annoyance to the child, 
and embarrass the respiration, they ought to be removed by means of a 
sponge mop, or camel's hair brush. This point in the treatment is a very 
important one, especially in young children. I believe that I have res- 
cued more than one patient by going three or four times a day, to make 
use myself of means by which to remove from the fauces the viscid, glue- 
like secretions, the purulent fluids, and the masses of pseudo-membranous 
exudation which collect in 'and occlude those passages, and which the 
child often cannot, by any effort of its own, get rid of. The best mode 
of effecting this object is by the use of mops, made of sponge or rag, fast- 
ened to a stick or whalebone, or by the injection from a small syringe or 
elastic bottle, of detergent washes or gargles into the throat, the mouth 
being held open and the tongue depressed by the handle of a spoon. One 
of the best washes for this purpose is one made of a strong decoction of 
green tea containing alum ; or we may employ sage tea and alum ; or 
honey of roses and borax, mixed with water ; or capsicum tea ; or, what 
is highly recommended by Dr. Watson, as one of the best, a solution of 
common salt. When coryza is present, the nasal passages should be 
cleansed by means of camel's hair brushes, or by the injection of some of 
the mild washes just referred to, and then freely anointed with sweet 
oil, or some mild ointment, or they may be touched with the wash used 
for the throat. To perform these little offices for the child almost always 
requires force, but they are followed by such comparative ease and com- 
fort, and I doubt not, such mitigation of the disease, that they ought to 
be insisted upon. 

For the otorrhcea which sometimes occurs, it is seldom necessary to do 
more during the violence of the attack, than to cleanse the ears twice or 



TREATMENT OF THE DROPSY. 543 

three times a day, by syringing with warm water and castile soap, or 
with a weak solution of alum. After the violence of the attack has sub- 
sided, this complication should be treated as in idiopathic cases. 

Treatment of the Dropsy. — In slight cases the only treatment necessary 
is the use of some mild purgative, as castor oil, magnesia, or a small dose 
of calomel, warm baths from time to time, minute doses of antimony and 
sweet spirits of nitre, a simple diuretic, as cream of tartar lemonade with 
sweet spirits of nitre, carefully regulated diet, and strict confinement to 
bed. 

In severe cases, on the contrary, marked by considerable fever, and in 
which the urine is scanty, high-colored, and loaded with albumen, or in 
which it is dark-colored, owing to the presence in it of blood, the treatment 
must be more active. Depletion is recommended under these circum- 
stances by nearly all the best authorities, some proposing venesection, 
while others prefer cupping or leeching over the loins. Without pretending 
to assert that bloodletting is unnecessary in this kind of dropsy, I 
will merely state that I have seen a number of children recover from 
it without any depletion whatever, and when the subject has been already 
much reduced by the previous illness, and where the blood is anemical 
and thin, I should certainly hesitate about drawing blood, unless the 
symptoms were very severe and threatening. If, however, the patient is 
not very pale and weak, and if the dropsy have attacked the internal cavi- 
ties or brain, or is threatening the brain, it would certainly be most pru- 
dent to draw blood. This may be done either by bleeding, when the 
patient is strong, or if in the opposite condition, by cupping or leeching 
the loins. 

After or without depletion, the treatment should consist in the use of 
active cathartics, unless there be some evident contraindicating condition 
present, of warm baths, and of diaphoretics. The patient should always 
be kept strictly confined to bed, and to a light and simple diet. The best 
cathartics are cream of tartar and jalap ) sometimes, especially when 
bilious symptoms are present, calomel, either in combination with or fol- 
lowed by some other cathartic ; and rhubarb or aloes. The saline purga- 
tives are condemned by most writers on account of their diuretic action, 
which is thought to increase the already irritated circulation of the kidneys. 
For my own part, I have generally made use of moderate doses of cream 
of tartar and jalap, given repeatedly until abundant watery stools were 
procured. Dr. West (Loc. cit. p. 477), contrary to most writers, states 
that he has " not found as much advantage from the employment of ca- 
thartics as from the use of diaphoretics." My own practice, after opening 
the bowels freely and copiously, has been to make use of diaphoretics, and 
particularly of small doses of antimonial wine or syrup of ipecacuanha and 



544 SCARLET FEVER. 

sweet spirits of nitre, taking care to avoid constant nausea. "Warm baths 
ought never to be forgotten. They may be used every night, or if the 
patient be too weak, or too irritable, for this remedy, we may substitute 
mustard foot baths. 

Diuretics are opposed by most writers in'" the early stage as injurious. 
After moving the bowels freely, and reducing somewhat the heat of skin 
and the frequency of the pulse by antimonial wine or by the warm bath, 
I have almost always made use of them, and never, that I am aware of, 
with any other effect than a beneficial one. The ones that I prefer are 
the cream of tartar and juniper berries, one drachm of each of which may 
be infused in half a pint of boiling water, and the whole of the clear 
fluid taken in the course of the day ; or tincture of digitalis and syrup of 
squills with acetate of potash, as follows : 

R. — Potass. Acetat., ^ii. 

Tinct. Digital., gtt. xlviii. 

Syrup. Scillae, gi vel ij. 

" Zingib., gvi. 

Aquae Fluvial., ^ij. — M. 

Give a teaspoonful every three hours to a child three or four years old. 

In giving digitalis, its effects upon the pulse and nervous system must of 
course be closely watched. 

In cases in which the brain is attacked, as indicated by violent de- 
lirium, coma, or convulsions, depletion ought, as a general rule, to be made 
use of. Venesection is usually most proper, but, if this cannot for 
any reason be employed, local bleeding by cups to the back of the neck or 
to the loins may be substituted. Active doses of cathartics ought to be 
given immediately after depletion, and if the symptoms are very urgent, 
enemata may be employed to hasten their operation. Warm baths are of 
great service in the treatment of this complication. They promote dia- 
phoresis, and thus moderate the febrile movement, and assist in removing 
the effusion. After these remedies, or in conjunction with them, diuretics 
are to be chiefly relied on. Those already recommended will answe 
perfectly well here also. In one case that came under my observation 
however, in which there was an almost comatose state with total 
suppression of urine for five days, the stomach was so irritable that no 
remedy scarcely could be retained. The child, nevertheless, recovered 
finally, under the use of watermelon seed tea, given frequently in small 
quantities, mustard foot-baths, and blisters behind the ears. (For further 
information in regard to the treatment of hydrocephalus following scar- 
let fever, the reader is referred to the article on hydrocephalus.) 

Prophylactic treatment. — It has been asserted that the use of bella- 






is 

: 



PROPHYLACTIC TREATMENT. 545 

donna by persons exposed to the contagion of the disease, has the power 
of imparting perfect or nearly perfect immunity from its attacks. My 
own experience in regard to this matter is so slight, from the fact that I 
have not resorted habitually to the belladonna as a means of prevention 
until quite lately, that any opinion I can offer is worth but little. I have, 
however, given it to nine children exposed directly to the disease, either 
from their being in a house in which it was prevailing, or in the very 
room of the patient. Of the nine, eight escaped the disease entirely, 
and the one who had it, had it very mildly and safely. From the evi- 
dence brought forward in the European works that I have seen, its effi- 
cacy seems to me to be left in considerable doubt. MM. Rilliet and Bar- 
thez are of opinion, however, that it is at least worthy of trial. Cazenave 
(Loc. cit. p. 58) states that " M. Biett saw the disease reign epidemically 
in one of the lofty valleys of Switzerland, and respect, almost without 
exception, children to whom the belladonna had been administered. " 
MM. Guersant and Blache (Loc. cit. p. 180), after citing various accounts 
of its use, conclude that " these trials ought, undoubtedly, to be con- 
tinued." According to Dr. Condie {Loc. cit. pp. 441, 442), Dr. Irwin 
made an extensive trial of its prophylactic powers in South Carolina, and 
found that of two hundred and fifty children who took it, less than half a 
dozen had the disease, and that very mildly. Dr. McKee, in an extension 
of the same epidemic, used it with like success. 

Dr. Condie himself made use of it, " but although redness and dryness 
of the throat, and a diffuse scarlet efflorescence were produced in the ma- 
jority of the cases, we never found it in any, to exert the slightest in- 
fluence in mitigating the character, or preventing the occurrence of scar- 
latina. The experiments were made during the prevalence of the disease, 
and in numerous instances, the subjects of them were attacked. In one 
case, the efflorescence was kept up by the use of belladonna, forty-eight 
hours; in a week afterwards, this individual took the disease in its 
most violent form, and died on the fourth day." 

By far the most thorough and careful examination of this interesting 
and important matter that I am acquainted with, has been made by Dr. 
F. Peyre Porcher (Charleston Med. Jour, and Rev., July, 1851). Dr. 
Porcher states that his paper contains the results of an examination of 
about four hundred volumes. Towards the end of the article (p. 476), Dr. 
Porcher gives us his conclusions in the following words : " In reviewing 
the testimony afforded by the preceding facts, our opinions, if we are allow- 
ed to express them, are decidedly in favor of the prophylactic power of bella- 
donna. However some may consider the evidence of a negative character, 
and therefore unworthy of confidence, yet, from its cumulation, from the 
careful way in which some observers conducted their inquiries, and from 

35 



546 MEASLES. 

the possibility of failures owing to the use of an inferior or badly prepared 
drug, we cannot but conceive that to discard it as utterly indecisive, 
would be indulging a spirit of irrational incredibility, leading to the re- 
jection of any amount of merely presumptive proof. But assuredly under 
circumstances like these, granting that the efficacy of the means is only 
problematical, none should hesitate to employ measures so simple in their 
application, and so safe in their consequences. The failure to avail 
ourselves of the prophylactic influence of belladonna, we cannot now 
but regard as a violation of those sacred obligations, which force us to 
leave nothing untried which may contribute so largely to the mitigation, 
or eradication, of one of the severest inflictions of the hand of God." 

Dr. Irwin gave it in the following manner. Three grains of the extract 
were dissolved in an ounce of cinnamon water, and two or three drops of 
the solution given morning and evening, to a child under one year old, 
and one drop more for every year above that age. 

Hufeland's formula is as follows, according to Rilliet and Barthez : — 

R. Extract. Belladonnse, gr. iii. 

Alcohol, 3J ; 

Aqua? Distillat., ^ss. 

A drop morning and evening for each year of the age of the child. 



ARTICLE II. 



MEASLES, RUBEOLA OR MORBILLI. 



Definition ; Frequency ; Forms. — Measles are an epidemic and conta- 
gious exantheme, characterized by catarrhal symptoms, continued fever, 
and an eruption, generally on the fourth day, of a crimson rash, in the 
form of stigmatized dots, like flea-bites, slightly elevated, which coalesce 
into irregular circles or crescents. It ends about the seventh day by des- 
quamation. 

The frequency of the disease is very irregular in different years, because 
of its epidemic nature. Thus, according to the tables of Dr. Emerson 
(Loc. cit.), the mortality from measles under twenty years of age, in the 
twenty years from 1807 to 1827, was 654. In seven of these years, 
(1807, 1809, 1813, 1817, 1818, 1821, 1822), not a death is recorded; in 
five, the deaths varied between one and eight for each ; while in the re- 
maining years, they were as follows : 20 in 1812 ; 38 in 1825 ; 47 in 
1820 ; 71 in 1808 ; 98 in 1826 j 99 in 1824 ; 106 in 1819 ; and 155 in 
1823. During the same period, the deaths from scarlet fever were, as 
has been already stated, only 93, which shows a great preponderance of 
measles. If, however, we compare these results with those obtained during 



causes. 547 

other periods, we shall find that scarlatina sometimes causes a much 
heavier mortality than measles. Thus, during the five years from 1544 
to 1848, inclusive, the deaths from measles were 311, while those from 
scarlatina were 1175, in number. To show still more completely the 
variable frequency of measles in different years, I may state that in 1S44, 
but 6 deaths from measles are reported; in 1845, 124; in 1846, 6; in 
1847, 77; and in 1848, 98. 

Measles appear, on the whole, to be a more common disease, and to 
attack a larger number of persons than scarlet fever, since, during the last 
eleven years, I have met with 288 cases of the former to 185 of the latter. 

I shall describe two form* of the disease; the regular or rubeola vul- 
garis ; and the malignant or rubeola maligna. I shall afterwards treat 
of its irregularities and complication?. 

Causes. — A chief cause of the disease is epidemic influence. Of this 
there can be no doubt, as it is proved by the evidence of all observers. 

Contagion. — Its infectious nature is universally admitted. This is 
thought to begin with the primary fever, and to continue up to the period 
of desquamation. The precise period at which it ceases is not however 
known. The disease may be carried in fomites. It has been propagated 
also by inoculation with the blood taken from a patient, and with serum 
obtained from the vesicles which sometimes accompany the eruption. 

The period of incubation is from five or six, to twenty days or even 
longer. The average period is about a week or ten days. In the inocu- 
lated cases the disease appeared about the sixth or seventh days. 

Killiet and Barthez conclude that measles are more frequent, less con- 
tagious, and have longer incubative and prodromic stages than scarlet 
fever. 

The same authors are of opinion that variola is somewhat more rare, 
rather more contagious, and that its period of incubation and its prodromic 
stage are a little shorter than those of measles. 

Measles, like other contagious diseases, rarely occur a second time in 
the same individual. 

Age. — I find by uniting Dr. Emerson's tables with some given by Dr. 
Condie (D/s. of Child, note, p. 100), that the disease appears to be most 
frequent between the age of 1 and 2 years, for while 395 deaths occurred in 
the second year, only 468 occurred between 2 and 5 years of age. This 
does not agree, however, with my own experience, since of 254 cases of 
the disease that have come under my observation, in which the age was accu- 
rately recorded, only 33 occurred in the second year, while 77 occurred be- 
tween the end of the second and the end of the fifth year. This discrepancy 
depends probably, in part at least, on the greater mortality of the disease 
during the earliest years of life, which would of course give a larger num- 



548 MEASLES. 






ber of deaths for those attached in the second, than for those in the third, 
fourth, and fifth years. The cases that have come under my own personal 
charge, occurred with equal frequency (33 for each) in the second and 
seventh years of life, and then in the following order: in the sixth (32); 
fifth (29), fourth (28), eighth (25) j first (18) j and ninth (9) ; and then 
in the eleventh, tenth, thirteenth, twelfth, and fifteenth. 

Sex. — It appears to be more common in the male than in the female 
sex. Of 264 cases that I have seen, in which the sex was noted, 145 
occurred in males, and 119 in females. 

Symptoms; Course; Duration. — Regular form of the disease. — Stage 
of invasion. — Measles begin with languor, irritability, sometimes chilliness, 
anorexia, aching in the back and limbs, fever, thirst, headache, and various 
signs of irritation of the mucous membrane of the eyes, nose, fauces, and 
larynx. 

The chilliness or horripilations which are mentioned by almost all 
writers, are difficult to appreciate in children. I have seldom known the 
child itself to complain of them, but upon inquiry of the mother or nurse, 
have sometimes been told that they had observed some coolness of the 
hands or feet, or a disposition to keep near the fire, and a desire for addi- 
tional clothing. These, therefore, are not important symptoms. Neither 
is the aching in the back and limbs, as it is seldom complained of, and can 
be ascertained in the older only by close questioning, or suspected in the 
younger by their complaining when they are moved. Fever is very rarely 
absent. It almost always comes on with, or very soon after the other 
prodromes, but in rare cases does not begin until the second day. It is 
almost invariably continued, after it once begins, except that it remits 
somewhat about daylight and in the early part of the morning, to become 
exacerbated again in the after part of the day. Its intensity increases, 
and the remissions become less distinct and shorter, as the time for the 
appearance of the eruption approaches. The pulse is increased in fre- 
quency, force, and volume, but rarely attains the same rapidity that it 
does in scarlet fever. At the same time the skin becomes warm and dry, 
the face is generally flushed, and there is considerable restlessness and 
irritability at first, often passing into quiet and drowsiness as the eruptive 
point approaches. The fever is accompanied by thirst, partial or complete 
anorexia, and generally by headache, which is frontal, and often com- 
plained of by children old enough to give an account of their sensations. 

Vomiting occurs sometimes, but not as a general rule. The catarrhal 
symptoms commence with, or may even precede the fever. They consti- 
tute the most characteristic symptoms of the disease, and indeed the only 
ones by which we are able to distinguish it with any certainty in the first 
stage. They are irritation and redness of the conjunctiva, especially that 



SYMPTOMS. 549 

of the eyelids, lachryraation, suffusion of the eyes, sensibility to light, 
stuffing of the nose, coryza, sneezing, slight soreness of the throat, cough, 
some constriction of the thorax, and slight dyspnoea. The state of the 
eyes and nose are very important as signs of the disease. They are not 
always present in the same degree, being very strongly marked in some 
instances, in others less so, and in some rare cases, absent. They are im- 
portant because there are few cases of ordinary cold in which they are 
present to -the same extent, or if so, the accompanying general symptoms 
are slight compared with those of measles. I have rarely known the 
faucial affection severe enough to elicit complaints, and never to produce 
difficulty of deglutition. It consists generally only of slight redness of 
the tonsils, soft palate, and pharynx, which is most strongly marked about 
the time that the eruption makes its appearance. The cough usually 
appears oo the first day. Infrequent and slight at first, it becomes more 
troublesome as the case progresses, until it assumes on the third or fourth 
day a character which is peculiar, and which may often lead to a suspicion 
as to the true nature of the attack. It is laryngeal, hard, dry, rather 
hoarse, and occurs generally in short paroxysms. At the same time the 
voice is often hoarse. 

The tongue is usually white and somewhat furred ; the bowels remain 
in their natural condition, or there may be slight constipation or diarrhoea. 
Constipation is most frequent, according to my own experience. The 
drowsiness, to which we have already alluded, often exists during the first 
stage. I have noticed it in a great many cases. The child, if undis- 
turbed, sleeps quietly for many hours, or for the greater part of one or two 
days, waking only from time to time to ask for drink, and then sinking 
off to sleep again. The symptom is not alarming unless it be connected 
with others which indicate local disease, or pass into coma, or alternate 
with marked delirium. Other nervous symptoms which sometimes occur, 
especially when the fever is violent, are restlessness, irritability, occasion- 
ally delirium at night, and in very rare cases, convulsions. Of 167 cases 
observed by Rilliet and Barthez, the latter symptom appeared in the first 
stage only in one, and was then confined to the eyeballs. I have met 
with convulsions in 5 out of 288 cases at the beginning of the eruption, 
and in one of which I shall not now speak, at the close of the eruption. 
In one of the cases the convulsions occurred on the first day, in a boy five 
years of age, of nervous temperament, and who had had several convulsive 
attacks during the process of dentition. The convulsions were general, 
but slight ; they lasted only a short time, and were not followed by any bad 
consequences. In the second case the sickness began with fever, drowsi- 
ness, tremulous movements of the hands, delirium, and in a few hours a 
slight general convulsion. On the second day there were two attacks of 



550 MEASLES. 

convulsions, both, however, slight. The other symptoms continued as 
before. On the third day the child was better, the fever having dimi- 
nished, and the nervous symptoms in great measure disappeared. On the 
fourth, fifth, and sixth days, the fever returned, and on the middle of the 
sixth day, a full measles rash made its appearance. There was no recur- 
rence of the nervous symptoms, and the case ended favorably. The third 
case occurred in a boy between seven and eight years old, of nervous and 
impressible temperament. The convulsive seizure took place just as the rash 
was coming out ; it was very slight, and lasted not more than one or two 
minutes. In the fourth case, in a boy in the second year of life, who had 
already had three convulsive attacks from other causes, showing thereby a 
manifest predisposition to that kind of disorder, the convulsions occurred as 
in the previous case, just at the coming out of the eruption. In this case 
also, the convulsions were slight, lasting only a few minutes. In neither 
of these two cases were the convulsions followed by dangerous symptoms. 
In the fifth and last case, the convulsions, as in the two preceding examples, 
occurred just as the rash was appearing; they were very slight, and were 
followed by no serious consequences. The subject of this case Was a girl 
between seven and eight years old, who had previously had an attack of 
convulsions produced by a severe febrile reaction occasioned by a simple 
angina, and another attack, caused by indigestion. 

MM. Guersant and Blache {Diet. de. Med. t. 27, p. 658) mention 
another prodromic symptom, which has sometimes enabled them to recog- 
nise the approach of measles before the eruption. This is a peculiar red- 
ness, a rose-colored punctuation, of the roof of the mouth, soft palate and 
uvula, differing from that of scarlatina. 

The duration of the prodromic stage is generally from three to four 
days. In a large majority of the cases that I have seen, the eruption has 
begun to appear in the course of the fourth day. This stage may, however, 
last only one or two days, or be prolonged to five, six, or seven, and, 
according to Guersant and Blache {Loc. cit. p. 659), it lasted in one case, 
with all the characteristic symptoms, fifteen days. In one case that 
occurred to myself, the subject of which was a girl between one and two 
years old, the eruption, owing no doubt to the presence of severe general 
bronchitis, did not make its appearance until the ninth day of the sick- 
ness, and even then it came out slowly and with much difficulty. The 
disease was known to be approaching from the fact that another child in 
the house had just recovered from an attack. In another case that came 
under my observation, in a girl between twelve and thirteen years of 
age, the eruption began to come out on the fourth day of the sickness, but 
was so faint and indistinct that I could not, until the sixth day, feel sure 
that it was a measles rash. Even after this the eruption continued pale 



SYMPTOMS. 551 

and insufficient until the seventh day of the eruption, when it was out fully 
and completely. 

Second stage, or that of eruption. — The eruption generally appears some 
time in the course of the fourth day, showing itself first on the chin or 
cheeks, or some other part of the face, and extending gradually to the 
neck and trunk, and finally to the extremities. It is often completed in 
from twenty-four to forty-eight hours. It begins in the form of distinct 
spots, not unlike flea-bites, of a more or less bright rose or crimson color, 
verging sometimes towards a deep red, of a roundish shape, with irregular 
edges, and of different sizes, varying between half a line and three lines 
in diameter. When fully formed they constitute true papulae, which are 
felt to be slightly elevated and firm to the touch, with broad, flat summits. 
When pressed upon, their color disappears, but it rapidly returns when 
the pressure is removed. Distinct and scanty at first, the spots or stig- 
mata soon become more numerous, and arrange themselves into clusters of 
an irregular crescentic or semilunar shape. The number of these clusters 
and the consequent general tint of the skin depend upon the amount and 
intensity of the eruption. In very mild cases, or when the eruption 
is imperfect, the clusters of papulae are few in number, and they are 
separated by large portions of healthy skin. In severe cases on the con- 
trary, the patches are so numerous, and coalesce so closely, that the skin 
assumes a general deep red tint. Yet it ought to be remarked, that it 
can be observed on close examination that the papulae never run com- 
pletely into each other, so as to form a continuous red surface, unless it 
be over very small spaces, and on certain parts of the surface, more parti- 
cularly the face. 

The fever does not diminish when the eruption makes its appearance, 
and it sometimes augments. The skin retains its heat ; the irritation of 
the eyes continues and is sometimes very severe ; the nostrils are dry and 
incrusted, or there is coryza, and in some few cases epistaxis. The face 
is at the same time flushed, independently of the eruption, the red color 
of the skin being observable in the intervals between the papulae, and it 
looks swelled and turgid, from tumefaction of the cheeks and particularly 
of the eyelids. The cough continues, and is loud, hoarse, and frequent in 
most cases, but in others short, scarcely hoarse, and but slightly marked. 
The voice is usually but not always a little hoarse. The respiration is 
slightly quickened in regular cases, but generally very little beyond the 
natural rate. The tongue is covered with a yellowish or whitish fur in its 
middle, while the edges and tip are clean and red. It remains moist and 
soft, unless some complication occurs. The tonsils, soft palate, and 
pharynx, present considerable redness, without tumefaction. The abdo- 
men commonly remains natural, though in some few cases there is slight 



552 MEASLES. 

soreness over its whole extent or in the iliac fossae. Slight diarrhoea often 
occurs at this time. It seldom lasts more than from one to three days. 
In other cases the stools are natural, or there may be moderate constipa- 
tion. The anorexia and thirst continue until the stage of decline occurs. 
About the time of the appearance of the rash, there is often considerable 
restlessness, anxiety, starting and twitching in sleep, slight delirium, and 
in children old enough to describe their sensations, complaints of head- 
ache. The strength of the patient is not decidedly affected in most of the 
cases. 

Stage of decline and desquamation. — The disease having reached its 
height in the course of the sixth day, the second of the eruption, it 
remains nearly stationary for one or two days longer, and begins to sub- 
side about the seventh or eighth of the disease, or third or fourth of the 
eruption. The eruption fades first on the face and neck, and has often 
very much or wholly subsided on those parts while it is still vivid on the 
extremities. The papulae lose some of their color, become less prominent, 
diminish in size, and when pressed upon do not disappear entirely as 
they did at first, but leave a dull or yellowish stain behind. A little later, 
they assume a dirty yellow or copperish tint, which does not disappear 
under pressure, showing that a slight ecchymosis has taken place into the 
substance of the derm. These stains continue a variable length of time, 
and are finally removed by absorption. As the eruption disappears, a 
slight furfuraceous desquamation takes place in a considerable number of 
the cases, but not by any means in all. This begins usually about the 
face, and may either be limited to that part, or extend to other portions 
of the body. It is seldom general, however, and is often scarcely notice- 
able. It occurs between the eighth and eleventh days of the disease, or 
fourth and seventh of the rash. 

From the moment the eruption passes its highest point of intensity and 
begins to decline, the other symptoms do the same. The pulse fast loses 
in frequency, and regains its ordinary characters. The heat of skin passes 
away, often with considerable perspiration, but sometimes with gentle 
moisture only. The various catarrhal symptoms subside; the cough is 
less frequent, loses its hoarseness, becomes softer, and gradually ceases. 
The tongue cleans off; appetite returns; thirst ceases; the restlessness 
and irritability disappear ; and the child returns to its ordinary condition 
of health. 

Irregularities of the disease. — Under this term I shall attempt to 
describe only the anomalous symptoms of the disease, which occur indepen- 
dently of complications. Those which are produced by the latter causes 
will be fully treated of when I come to consider the subject of the compli- 
cations. 



SYMPTOMS. 553 

In some cases, the symptoms of the prodromic stage are so slight that 
they pass almost unobserved, and the child is scarcely thought to be sick 
until the rash makes its appearance. In others, owing to some peculiarity 
of the temperament, or to the state of the constitution at the time, they 
are much more severe than usual, or some one symptom may be in excess. 
In one case that came under my own observation, in a girl seven years old, 
the nausea and vomiting were very distressing, and were accompanied by 
the most intense frontal headache. She complained precisely as children 
generally do with tubercular meningitis, and was, moreover, extremely 
restless, and at night delirious. Nevertheless, the eruption came out on 
the fourth day, and was perfectly regular in its characters and course ; the 
unpleasant symptoms ceased from that moment, and the patient recovered 
without any further bad symptoms. I have already spoken of five cases 
accompanied by general convulsions at the commencement of the first 
stage. The course of the disease in the subsequent stages, was regular in 
all respects. In two other cases, in girls, sisters, seven and nine years 
old respectively, of highly nervous temperament, the headache in the first 
stage was so intense as to require the application of leeches for its relief; 
yet the disease was regular in its other characters. 

The eruption presents various irregularities which ought to be noticed. 
It has already been stated that the amount of the rash varies according to 
the severity of the case, although in other respects regular. Sometimes 
the papulce are comparatively small in size and few in number, and conse- 
quently, the clusters in which they are arranged have considerable spaces of 
healthy skin between. When this is the case, the stigmata are usually rough, 
lighter in color, and from this circumstance and the fact that the spaces 
between the clusters are large, the general tint of the skin is much less 
deep than in severer cases, in which the opposite of these characters pre- 
vails. In some of the mildest cases, the amount of eruption upon the 
extremities has been very small, and after forming, it has suddenly, in the 
space of a night, faded to such a degree as to seem almost a retrocession. 
But as this sudden disappearance has not been accompanied or followed 
by bad symptoms, it is clear that its cause was merely the great mildness 
of the attack. In such instances the general symptoms have always been 
slight, and the whole duration of the sickness shorter by two or three days 
than in severe cases. 

I have already described the dull yellowish stains which remain after 
the papulae have faded. These stains sometimes assume, in malignant 
cases, a livid or purplish hue, from the occurrence of passive hemorrhage 
into the tissue of the derma. They may, however, assume a dark and 
purpureous appearance, without any malignant or dangerous symptoms 
whatever. This happened in a family in which I attended seven cases 



554 MEASLES. 

of the disease in 1845. In three of them (boys of 10, 5, and 1 year old, 
respectively), the eruption, which was copious and regular in all, became 
in a single night, at the moment of decline, of a dark brown or light pur- 
ple hue. The spots did not disapppear at all under pressure, and were 
evidently formed by true ecchymoses. The general symptoms were all 
favorable. The only peculiarity to be observed was that the fever had 
disappeared very suddenly, and that the extremities were slightly cooler 
than natural. The convalescence was as usual, except that the ecchymotic 
spots disappeared very slowly and gradually. 

Several authors describe a form of measles without eruption. They state 
that during the epidemic prevalence of the disease, some children present 
all the catarrhal and febrile symptoms, without the eruption, and that 
they are protected against future attacks. The last assertion, at least, 
must be very difficult to prove. For my own part, I have never, met 
with such cases, and should I ever seem to do so, would certainly not call 
them measles, lest by so doing the parents might be induced, on future 
occasions, to expose the child unnecessarily to the disease, when, should 
any evil consequences follow, they might justly question the wisdom of the 
physician. 

Willan and other authors have described another variety of the disease 
to which is applied the term rubeola sine catarrho, or measles without ca- 
tarrhal symptoms. Such cases are said to present no catarrhal symptoms 
whatever, and little or no febrile reaction. They are stated, moreover, 
to occur generally during the epidemic prevalence of measles. Most 
authors agree that this form does not protect the constitution against the 
true disease, and some regard it only as an eruption resembling measles, 
dependent upon gastric disorder. I at present recollect perfectly three 
cases of eruption in children, which, had they been accompanied by 
cough and fever, I should certainly have called measles. They all oc- 
curred in infants. The rash was preceded for two or three days by 
feverishness, uneasiness, restlessness during sleep, and slight diarrhoea, 
after which the eruption suddenly made its appearance and covered the 
whole integument within twenty-four hours. There were no catarrhal 
symptoms whatever. At the same time the febrile symptoms disap- 
peared and the children seemed quite well. The eruption never lasted 
over forty-eight hours, and disappeared without leaving a trace behind. 
They were, no doubt, cases of roseola. 

Rubeola Maligna. — This form may occur either as an epidemic or 
sporadic affection. Generally, however, it prevails as an epidemic, and 
depends upon some peculiarity which it is impossible to understand. The 
few sporadic cases which are met with, may be traced generally to some 
vicious state of the constitution of the individual, or to the unfavorable 



COMPLICATIONS. 555 

hygienic conditions in which he is placed. The symptoms assume ataxic 
or adynamic characters, which give to the case the features of the typhous 
or typhoid type of disease. They may make their appearance in the pro- 
dromic, or, as happens more frequently, not before the eruptive stage. 
When they begin in the first stage, the case is marked by great frequency 
and feebleness of the pulse ; by prostration ; by unusual dyspnoea and 
oppression ; and especially by greater violence of the nervous symptoms, as 
delirium or stupor. Sometimes, even in this stage, petechiae make their 
appearance, and there is lividity and soreness of the fauces, with discharges 
of dark blood from the nostrils, and sometimes profuse and exhausting 
diarrhoea or dysenteric discharges. When the time for the eruption to 
appear arrives, this comes out slowly and imperfectly, or irregularly, and 
generally assumes a livid, purplish, or blackish color, owing to the passive 
exudation of blood into the papules, and hence the name sometimes given 
to such cases, of Rubeola Nigra, or black measles. This form of the dis- 
ease assumes in fact, many of the features of purpura hemorrhagica. The 
patient may die of exhaustion, of congestion of some important organ, as 
the brain or lungs, of the diarrhoea or dysentery which sometimes compli- 
cate the disease, or finally of the hemorrhages which occur in consequence 
of the dissolved and fluid state of the blood ; or he may, after a severe 
struggle with the violence of the disease, recover his health. 

Complications and sequels. — MM. Rilliet and Barthez begin their 
chapter on the complications of the disease, with the following excellent 
remarks. " Rubeola manifests itself by an inflammation or inflammatory 
fluxion of the skin and all the mucous membranes. The regular course 
of the disease depends upon the conservation of a due equilibrium between 
these two kinds of fluxions. That which is seated in the skin ought in 
general to predominate: if the equilibrium be destroyed by any cause 
whatever, whether accidental or inherent to the disease, if the predomi- 
nance of the inflammation takes place in the mucous membranes, there 
will result a phlegmasia of some one of those tissues. 

" It is easy to foresee, by attention to these circumstances, that the in- 
flammatory complications of measles will be most apt to fall upon the 
mucous membranes, and that broncho-pneumonia, pharyngo-laryngitis, and 
intestinal inflammations will be the most frequent of all." 

Bronchitis and Pneumonia. — These constitute by far the most frequent 
and important of the complications of measles. In 167 cases, Rilliet and 
Barthez met with 24 cases of bronchitis, 7 of pneumonia without bronchitis, 
and 58 of lobular broncho-pneumonia. This statement shows how very 
large a proportion of the cases of measles occurring in the Children's Hos- 
pital at Paris, became complicated in the course of the attack. The pro- 
portion in private practice is much smaller, since in 288 cases, I have met 



= 



556 MEASLES. 

with only 24 of bronchitis, and 5 of lobar pneumonia. These are, however, 
in private practice, according to my experience, much the most importan 
of all the complications likely to occur. Of 6 deaths which occurred i 
the 288 cases that I have seen, 3 were caused by bronchitis. 

The time at which these different complications make their appearance 
is important. They may occur during the prodromic stage, early in the 
eruptive stage, during the decline of the eruption, or after the eruption. 
The most common period for their occurrence is the prodromic stage. It 
is difficult or impossible to ascertain their causes in a great many cases. 
In some instances they depend evidently upon cold. Age has some 
influence upon their production, as bronchitis is most apt to occur in 
young children, whilst lobar pneumonia attacks those who are older. 

The physical signs of these affections are the same as when they exist 
in the idiopathic form. The rational signs are increase of cough, which, 
instead of being merely laryngeal, becomes deeper and either pneumonic 
or catarrhal, and dyspnoea, which is sometimes excessive, the number of 
respirations mounting up to 40, 50, and, in severe cases, to 60 and 80. 
The pulse is more frequent than in regular measles, and in very bad cases 
becomes rapid and small ; the skin is hot and dry j the face is pale and 
anxious in severe cases, in which the eruption does not appear ; and the 
child is generally restless and irritable, with broken, irregular sleep, or in 
the most violent cases, it is dull and soporose. In two of the fatal cases 
that came under my observation, convulsions occurred. It should be re- 
marked, however, that in one, the child, a boy only nine months old, was 
laboring under an attack of hooping-cough, and that it was in one of the 
paroxysms of that malady, that death took place. In the other case, 
that of a boy eighteen months old, the convulsions occurred first on the 
day of the eruption, and then ceased, to recur again the third day after- 
wards. The bronchitis dated from before the appearance of the eruption, 
and was no doubt the cause of the convulsions and death. 

When a pulmonary complication begins in the prodromic stage, it 
almost always modifies the eruption in some manner, either retarding or 
rendering it irregular or imperfect. When it dates from the second stage, 
it may cause a partial or complete retrocession of the eruption. I have 
known the eruption to be retarded several days, so as not to come out 
until the fifth, sixth, or even ninth. When the rash does appear, whether 
at the usual period or later, it is evidently with difficulty. It is pale and 
scanty, or abundant on one part of the body, and scanty on another, or it 
appears and disappears alternately. At length it either comes out fully, 
and the threatening symptoms pass away, or the eruption lasts the usual, 
or nearly the usual length of time in its pale and imperfect condition, 
and the child recovers slowly and gradually from the complication, which 



COMPLICATIONS. 557 

has become the most important part of the sickness ; or, in fatal cases, the 
symptoms grow worse and worse, and the child dies after a few days, or a 
longer time, according as the inflammation assumes the acute or chronic 
type. 

Whenever it is observed in a case of measles, that there is more drowsi- 
ness or irritability than usual, or that the pulse is more frequent or stronger 
than it ought to be, it becomes important to ascertain carefully the state 
of the respiration. If this be accelerated, the thorax ought to be examined 
with strict attention by auscultation and percussion, to discover whether 
there be not some pulmonic inflammation at work, likely to convert the 
disorder from a mild one, as it almost always is when uncomplicated, into 
one dangerous to life, which it will assuredly become, should any pulmonic 
complication be allowed to steal unawares upon the patient. 

The prognosis of the pulmonic complications of measles would appear to 
be very unfavorable in hospitals for children, since Rilliet and Barthez 
state that scarcely one patient in four or five recovered. Of the 29 cases 
that I have seen, I have already stated that 3 died of bronchitis, and if 
we recollect that one of these was complicated also with pertussis and 
morbid dentition, it will be seen that the prognosis is, as might be 
expected, vastly more favorable in private than in hospital practice. 

Laryngitis is a common complication of the disease. The authors just 
quoted, met with it in 35 of their 167 cases. It occurred in 8 of the 288 
cases that came under my observation. It is often accompanied by pha- 
ryngitis. 

Autopsies show that the laryngitis may be slight, severe, or accompanied 
with pseudo-membranous exudations. The inflammation may be simple, 
therefore, consisting merely of different degrees of redness, or of redness 
with thickening and softening of the mucous membrane ; it may be more 
intense and accompanied by ulcerations or erosions ; or, lastly, it may be 
associated with an exudation of false membranes. 

The symptoms of this complication will depend upon the form the 
inflammation assumes. It is unnecessary to describe them here, as they 
are the same as those of the idiopathic affection, which has already been 
fully treated of. 

The occurrence of laryngitis exerts but little influence on the rash, 
particularly as it almost always appears during the decline of the latter. 
It is seldom fatal, unless it assume the pseudo-membranous form. The 
eight cases that came under my observation were attacks of the simple 
disease, and they all recovered. 

Inflammation of the intestines. — According to Rilliet and Barthez, 
lesions of the intestinal mucous membrane are the most frequent complica- 
tions after pulmonary affections. About a third of the cases presented at 



558 MEASLES. 

the autopsy erythematous inflammation of the mucous membrane; a fifth 
offered follicular entero-colitis, a seventh ulcerative inflammation, and a 
fourth softening. Some presented several of the lesions united, and in a 
few no lesion was found, though the symptoms of entero-colitis had 
existed during life. I give these data from the above authors, not because 
they apply to private practice generally, but merely in order to show what 
are the tendencies of the disease, when disposed from unfavorable hygienic 
conditions to take on complications. I have met with only seven instances 
of intestinal inflammation in the 288 cases that have come under my own 
observation. Four of these occurred in the same family, in children of 
seven, five, three, and one year old respectively. They were cases of 
entero-colitis, accompanied in two, with dysenteric symptoms, and all 
made their appearance towards the close of the disease. The three 
remaining cases were attacks of dysentery, one of which was very severe, 
the stools amounting to twenty in the day, while the other two were much 
less so. 

The intestinal complications may appear during the prodromic stage, or 
on the day of eruption, and if not at one of those periods, they are most 
apt to occur during the decline of the rash. The slight cases, constitut- 
ing the common diarrhoea of the disease, generally begin early, whilst the 
grave cases usually date from a later period of the disease. The causes 
of these complications seem to be various exciting agents acting upon a 
mucous membrane predisposed, by the nature of the disease, to inflamma- 
tory action. These agents are said to be generally improper food, giving 
rise to indigestions; and the too early use of purgative remedies, and 
laxatives. In the cases observed by myself, it was impossible to detect 
the causes. 

The symptoms are more or less abundant diarrhoea, and in some, but 
not all the cases, sensibility with tumidity and tension of the abdomen. 
This complication does not exert much influence upon the measles, which 
usually pursue their regular course. Sometimes, however, it occasions an 
aggravation of the febrile symptoms, and when of a grave character, may 
no doubt interfere with the regular progress of the eruptive disease. 

According to Eilliet and Barthez, this complication was very seldom the 
only, or even chief cause of a fatal termination. Scarcely five or six of 
all that they observed, could be considered as of that kind. It increases 
very much, however, the danger of the pulmonic attacks, for the latter 
are much less serious, so long as they exist alone, while as soon as intes- 
tinal inflammation is added to them, they become almost necessarily 
fatal. The seven cases that I met with recovered under simple treat- 
ment. 

In a considerable number of cases, a slight diarrhoea, to which I have 



COMPLICATIONS. 559 

already referred as a common event in measles, occurred, but only in the 
seven above mentioned did it amount to a serious complication. 

In one case that came under my observation, in a girl between five and 
six years old, fatal congestion of the brain occurred just as the rash was 
disappearing. There was no evident cause whatever for this accident. 
There had been no imprudence either as to diet or exposure. The child 
was, however, of a tubercular family, the mother having at this very time, 
tubercular disease of the lungs. The eruption had come out well and pro- 
perly, and continued to do so on the second day without any bad, irregular, 
or threatening symptom. On the third day of the eruption, this began to 
decline, and the child had an attack of spontaneous vomiting, but con- 
tinued through the day cheerful and pleasant. The night of that day 
was restless and feverish, and she wanted much drink. On the fourth 
day she was drowsy and heavy, and complained of her head. I saw her 
first in the evening of this day. She was then very dull and heavy, 
scarcely answering questions, and protruding the tongue slowly, and after 
much urging. She had some little, but not a troublesome, cough. 
Careful examination revealed no disease of the thoracic organs. The 
respiration was natural, and the pulse was full and very frequent. On 
the morning of the fifth day, the patient was comatose, neither answering 
questions, nor protruding her tongue. In the course of the day, there 
were some irregular convulsive movements. In the evening the right 
arm was rigidly flexed at the elbow, and the left one stiffly extended. 
The patient died that night. 

In another case death occurred from sudden effusion of serum into the 
internal cavities, caused apparently by the existence of an excessively 
hydrsemical state of the blood, which had been allowed to come on 
gradually, without any attempt on the part of the parents to seek a 
remedy during the slow approach of this condition of the circulating 
fluid. The case occurred in a boy in the second year of his age, and 
who had a phthisical mother. The attack of measles took place in the 
last week of January, 1852, and was regular, and not, according to the 
parents, I not having seen the child, at all severe or dangerous in any 
respect. After the attack was over, however, and though he was running 
about the house as before, he continued to look more and more pale and 
sickly until the evening of February 25th, when, suddenly, after lip. M. 
he was seized with fever, and became very restless. On the following 
day, at 9 A. M., I saw him. He was then extremely pallid, and was drowsy 
and heavy ; the breathing was rapid and oppressed, the pulse very 
frequent, and the skin hot and dry. He was evidently dropsical, as both 
the face and hands, and the feet also, were puffed, smooth, and doughy. 
The bowels had not been opened the previous night. In the evening 



560 MEASLES. 

the pulse was 170 ; the skin was still hot, and the breathing very rapid 
and much oppressed. There was scarcely any cough. The percussion 
was dull over too large a space in the precordial region ; the cardiac im- 
pulse was obscure, and the sounds were indistinct and muffled; there was 
no bellows-murmur. The percussion was dull over the inferior dorsal 
regions. No rale whatever was heard. The child died on the following 
morning at 3£ o'clock. Ten minutes before his death, he asked for a 
drink, lifted himself up in bed, drank freely, looked round intelligently, 
and then laid down and died. At the autopsy, the subcutaneous cellular 
tissue was found to be infiltrated with serum. ' On puncturing the right 
pleural sac, there was an immediate escape of a clear, straw-yellow serum. 
There was considerable effusion in the left pleura also, but less than in 
the right. The pericardium contained at least two ounces of serum, so 
that it was pushed off to a considerable extent from the heart. There 
was a slight pleuritic adhesion of the upper lobe of the right lung to the 
ribs. This was, however, evidently of an ancient date. There was no other 
inflammation of the pleuree, and none of the pericardium. Both lungs 
contained tubercles, not very numerous, but of considerable size in the 
upper lobes. There was no pneumonia, but both lungs were somewhat 
congested. The heart was larger than usual. In the right auricle there 
was a rather large, and white, but soft concretion, and a smaller one in 
the right ventricle. The left cavities presented no concretions. The 
valves were healthy. 

There are several other disorders which sometimes complicate or follow 
measles, but as I have already given as much space to this subject as the 
limits of the work will allow, I shall be satisfied with a simple enumera- 
tion of them. They are otitis, ophthalmia, hemorrhages, stomatitis, 
anasarca, and different cerebral symptoms. I will merely add, that mea- 
sles are supposed by many observers to have a special tendency to de- 
velope tubercular disease in the system, and that it is necessary, there- 
fore, to treat a child, showing any predisposition to that diathesis, or one 
born of tubercular parents, with particular caution, both at the time of 
the disease, and during the convalescence. It is not uncommon for mea- 
sles to be conjoined with other eruptive diseases. I have known it to co- 
exist with scarlatina in two instances, and Dr. Gr. B. Wood has met with 
a fatal case of the same nature. It may be associated, likewise, with 
variola, or with erysipelas, of which I have met with one instance. I 
will mention here that of the whole 288 cases of measles that I have ob- 
served, 235 were simple, and 53 complicated. The complications were as 
follows : bronchitis, 24 ; pneumonia, 5 ; laryngitis, slight or severe, 8 ; 
dysentery, 7 ; pertussis, 7 ; scarlatina, 2 ; convulsions in the early stage 
of the disease, 5, and in the latter stage, 3; erysipelas, 1; meningitis, 1; 



LESIONS — DIAGNOSIS. 561 

congestion of the brain, 1 ; serous effusion into the internal cavities, 1. 
It ought to be observed, however, that in the above enumeration, several 
cases are referred to twice, and one, a case in which pertussis, bronchitis, 
and convulsions occurred, three times. 

Anatomical Lesions. — It is difficult to ascertain what are the cha- 
racteristic lesions of measles, because of the fact that most of the fatal 
cases prove so in consequence of some complication. Some few fatal 
cases, however, of the regular form, and some in which the complication 
was so slight as not to be likely to change the autopsical appearances much, 
have led to the following conclusions. 

The lesions peculiar to measles are general congestion of different organs, 
which are colored red from the imbibition of blood and sometimes softened. 
The congestion affects the mucous membranes particularly, and imparts 
to them a reddish or slightly blackish color. In some of the cases there 
is morbid development of the intestinal follicles. The most important 
lesion, however, is that of the blood, which presents the appearances com- 
mon to the class pyrexiae. These are normal proportion or diminution of 
the fibrinous, with increase of the globular element of the blood. Dr. 
Copland (Diet. Pract. Med. vol. ii. p. 819) gives the appearances in a 
few fatal cases of malignant measles. They were softening of the tissues 
and the facility with which they were torn; the presence, in some of the 
cases, of a turbid or sanguineous serous fluid in the serous cavities; 
general congestion of the lungs; dark appearance, and livid or purple 
ecchymoses of the bronchial mucous surface of the fauces, stomach, and 
caecum; engorgement with dark and semi-fluid blood of the veins and 
sinuses of the brain, and of the auricles and large veins; and finally a 
livid and mottled appearance of some parts of the body, with petechige of 
a dark color. 

Diagnosis. — It is impossible to diagnosticate measles in the first stage 
with any considerable certainty. The existence of the disease may be sus- 
pected in that period from the appearance of the eyes, from the coryza 
and sneezing, the frequent, hoarse, scraping cough, and the fever, head- 
ache, and thirst. If, in connexion with these symptoms, it happens that 
an epidemic of measles be prevailing at the time, or that the child has 
been exposed to the contagion of the disease, the inference becomes still 
more plausible. Nevertheless, any opinion upon this point ought to be 
given with much reservation. 

After the eruption has come out fully it is not likely to be mistaken 
for any other disease, unless it be roseola, the rash of which sometimes 
resembles that of measles very closely. It may be distinguished, how- 
ever, by attention to the concomitant symptoms, — by the slight degree of 
fever, the more rapid evolution of the rash, and the absence of the pe- 

36 



562 MEASLES. 

culiar catarrhal symptoms in roseola. In the very early stage of the 
eruption, measles may be confounded with variola. A careful attention, 
however, to the size and shape of the papulae, which are much larger, 
flatter, and less elevated in measles, and the presence of the catarrhal 
symptoms, will usually suffice to show the difference even in the earliest 
stage. A little later, the appearance of vesicles on some of the papulae 
about the face in variola, will show the difference still more strongly. 
The distinction between measles and scarlatina has already been drawn 
in the description of the latter disease. It rests chiefly on the much 
shorter duration of the prodromic stage, the greater violence of the angi- 
nose symptoms, the absence of the peculiar catarrhal symptoms, and the 
more rapid evolution of the eruption in the latter disease ; and lastly, on 
the differences in the two eruptions, observable especially at their first 
appearance. 

When measles are conjoined with some other eruption, the diagnosis is 
to be made out by a careful study of the prodromes and of the eruption 
on different parts of the body, for we can generally find well-marked 
patches of the rash peculiar to each on some portions of the surface. In 
one of the cases of measles and scarlatina that I saw, the latter disease 
was developed first. The eruption made its appearance in the usual 
form ; on the second day of the eruption, the child was seized with hard, 
hoarse, laryngeal cough, and with redness of the eyes and lachrymation. 
These symptoms continued three days, at the end of which time the scar- 
latinous rash had disappeared from the face, but remained visible upon 
the trunk and extremities. Characteristic measly papulae now made 
their appearance on the face, and pursued their regular course, while on 
the trunk and extremities, the measly eruption was never well defined, 
being mixed with and disguised, as it were, by that of the scarlatina. In 
the other case, the measles appeared first and went on regularly until the 
eruption was declining, and the general symptoms moderating, when sud- 
denly the fever, heat of skin, restlessness, and irritability returned, and 
the child was very soon covered with the punctuated scarlet rash of scar- 
latina. 

Prognosis. — The prognosis of simple, uncomplicated measles is very 
favorable; the cases almost always recover without difficulty. This is 
shown to be true by the following facts. Killiet and Barthez report 36 
cases of simple measles, of which all but one recovered. Of 235 cases 
that I have seen, all terminated favorably. When, on the contrary, com- 
plications occur, the disease always becomes more or less dangerous, the 
degree of danger depending on the nature of the intercurrent affection, 
and on the hygienic conditions in which the patient is placed. Thus, of 131 
cases observed by the above authors, in which some form of complication 



PROGNOSIS. 563 

occurred, 89 or about two-thirds proved fatal, while of the 53 complicated 
cases that I have seen, only 6 were fatal. It must be recollected that the 
cases of the French observers all occurred under the unfavorable hygienic 
conditions of a large hospital, in children of bad constitution from con- 
genital or acquired causes, whilst mine were observed in private paractice, 
where the hygienic conditions are favorable in the same degree as they 
are unfavorable in hospitals. 

The six fatal cases that came under my observation, proved so from the 
circumstances I am about to mention. The first occurred in a child nine 
months old, who was laboring under pertussis when attacked with measles. 
Bronchitis supervened upon the measles, and proved fatal by convulsions, 
which came on during a paroxysm of hooping-cough, two weeks after the 
disappearance of the rubeola. The second case was that of a boy 
eighteen months old, who was prescribed for by an apothecary from be- 
hind his counter, until I saw him. The eruption made its appearance 
imperfectly, I was told, with a convulsion. After this, he was very rest- 
less, and had rapid and difficult respiration and much cough. On the 
morning of the fourth day of the eruption, this had almost entirely disap- 
peared, and the child was again attacked with convulsions. I saw him 
shortly after this for the first time, and found him comatose, with convul- 
sive movements of the limbs, extreme dyspnoea, and all the symptoms of 
extensive bronchitis of both lungs. He died thirty-six hours from this, 
as was to be expected. The third was a case of pneumonia in a child 
between one and two years of age, in which the inflammation came on 
as the eruption was fading, and proved fatal in spite of all that could 
be done, on the eleventh day. The fourth occurred in a boy between 
four and five years old, who appeared to recover perfectly from the 
measles, but was attacked in ten days with meningitis, and died. The 
fifth was the case of congestion of the brain already detailed in the re- 
marks upon complications, as proving fatal shortly after the decline of the 
rash. The sixth was that of sudden dropsical effusion into the internal 
cavities, also described in the remarks upon complications. 

To conclude, we may state that the prognosis is always highly favorable 
under the following circumstances: when the disease is primary; when 
the prodromic stage is of the proper duration ; when the eruption begins 
upon the face and extends gradually to the rest of the body; when the 
febrile movement is moderate ; when the eruption, after increasing for one, 
two, or three days, gradually decreases ; when the cough and other con- 
comitant symptoms diminish with the fever ; when the cutaneous surface, 
after the fading of the rash, assumes a natural color, and is neither 
flushed nor pale ; when the appetite returns, the disposition to be amused 
and take notice continues, and lastly when the sleep is natural. 



564 MEASLES. 

On the contrary, the prognosis becomes unfavorable under the follow- 
ing circumstances: when the prodromic stage lasts longer than usual, and 
when it is accompanied by violent symptoms of any kind, as extreme jacti- 
tation, irritability, dyspnoea, much stupor, coma, or convulsions; when 
the eruption is irregular in its appearance or course ; when the fever does 
not disappear with the eruption, whether it remains violent or assume the 
form of hectic ; when, after the eruption, the face continues deeply flushed 
or becomes very pale ; when the cough, dyspnoea, or diarrhoea persist ; and 
lastly, when the child remains weak, languid, dispirited, or irritable. 

It may be stated in conclusion, that the prognosis of measles is always 
favorable in proportion to the health of the child at the time of the inva- 
sion, and the regularity with which the disease passes through its diffe- 
rent phases ; while it becomes unfavorable, though far less so in private 
practice amongst people in easy circumstances, than in hospitals or amongst 
the poor and wretched, whenever it attacks a child already laboring under 
some disease, and when it becomes complicated with any other malady, 
either local or general. 

Treatment of the Regular, Simple Form. — This form requires in 
a large majority of the cases little other treatment than strict attention to 
the hygienic condition of the patient, the use of simple diaphoretics, of 
mild cathartics occasionally, and the palliation of any of the symptoms 
that may chance to become somewhat more troublesome than usual. 

Hygienic Treatment. — The child ought to be confined as much as 
possible to bed in a large, well-ventilated chamber. Every precaution 
should be observed to prevent chilliness, while at the same time it is 
nearly, if not quite as important, to avoid over-heating the patient, either 
by excessive clothing or by keeping the temperature of the room too high. 
In winter, it is well to direct the temperature to be maintained at between 
68° and 70° F., night and day. If this be done, the child is not apt to 
take cold, even though it be uncovered at times, and yet the warmth is 
not oppressive. I have often remarked that this temperature is just what 
it ought to be when the room is well ventilated, either by means of an 
open fire-place, or by communication with adjoining rooms; but when, on 
the contrary, the room is heated by a furnace flue, and not ventilated at 
all or very imperfectly, the same temperature as indicated by the ther- 
mometer becomes extremely close and oppressive. Under such circum- 
stances, a door into an adjoining room, or if this cannot be, one into the 
entry, ought to be kept more or less open, with a screen of some kind be- 
tween it and the child, in order to secure a good ventilation, which is as- 
suredly of the very highest importance, and yet to prevent by the screen 
a current of cool air from chilling the patient. The diet during the febrile 
period ought to be very light. It may consist of milk and water, of arrow 



TREATMENT. 565 

root, sago, or tapioca, prepared with milk or water; or of crackers soaked 
in water, with salt, or some similar food. When the eruption and fever 
have in great measure disappeared, some light broth, either vegetable or 
animal, with dry toast or bread, plain boiled rice, a roasted potato, or 
ice cream, may be added; and after all the symptoms have ceased, the 
usual diet can be gradually resumed. The drinks may consist of simple 
water, of lemonade, orangeade, gum water, or flax-seed tea, with the ad- 
dition of a little sweet nitre ; or of weak infusions of balm, sweet-marjoram, 
or saffron. They may be given in any reasonable quantity, at the tem- 
perature of the room. Some persons have a great dread of cold water in 
the disease. I have never seen small quantities (half a wineglassful to a 
wineglassful at a time) of the coldest water do any harm, and believe it 
to be useful when the fever is violent, and the heat very great. I once, 
however, saw a boy nine years old, attacked with violent colic and partial 
retrocession of the eruption, after swallowing suddenly a tumblerful of 
iced water. The unpleasant symptoms passed off in a few hours, and he 
had no difficulty afterwards. 

The child should not be permitted to leave the room until a few days 
after the entire disappearance of the disease. It ought to be kept in the 
house until it has regained in some measure its strength and healthful 
looks, as it will scarcely be able to resist exposure before. 

Therapeutical Treatment. — The therapeutical management of the 
regular form ought to be very simple. When the bowels have not been 
opened naturally for one or two days, it is proper to direct an enema to 
be used, or, if the fever and restlessness are considerable, some mild laxa- 
tive, as a teaspoonful or dessert-spoonful of castor oil, a dessert or table- 
spoonful of syrup of rhubarb, half a teaspoonful of magnesia for older 
children, or less for younger, or some similar remedy, always selecting 
those which are mild, and giving them in small doses, lest they irri- 
tate the gastro-intestinal mucous membrane. It is better to give a small 
dose and repeat it in four or six hours, or assist it by an enema, than to 
give such a quantity as might produce over-purging, and thus perhaps 
disturb the regular progress of the eruption. The laxative may be re- 
peated from time to time throughout the disease, if the bowels are not 
moved naturally. After the laxative we may either do nothing, when 
the case is mild and when it progresses favorably, or else give one of the 
infusions above mentioned, or a little sweet spirits of nitre. If the reac- 
tion, however, be considerable, with much headache, restlessness, and dry, 
hot skin, I would give small doses of antimonial wine and sweet spirits of 
nitre (from one to three or four drops of the former, with five or ten of 
the latter), every two hours, and direct a warm mustard foot-bath to be 
given twice a day. If the fever be violent, with frequent, strong and full 



566 MEASLES. 






pulse, intense heat of skin, severe headache, and much restlessness, even 
without any present sign of local disease, it would undoubtedly be correct 
to resort to moderate depletion, in order to prevent the formation of any 
local affection, or to relieve any which may be in process of formation, 
though not as yet indicated by local symptoms. Of the 235 regular 
cases that I have seen, depletion was employed only in 2 : in one a vene- 
section of four ounces in a boy seven years old, in consequence of the 
great violence of the reaction, and not from any discoverable local affec- 
tion; and in the other, the application of leeches to the temples, for in- 
tense headache, in a girl nine years old. Under the same circumstances 
a warm bath, given with care, and continued for fifteen or twenty minutes, 
will be found of great service ; or, a simple foot-bath may be used and re- 
peated three or four times in the course of a day. 

If any of the local symptoms become particularly troublesome, they 
should be palliated by simple treatment. When the cough is very fre- 
quent and hard, it is most effectually moderated by some anodyne, which 
may be given in most cases without any detriment. The only contra-in- 
dication to its use is the presence of severe headache or some other cere- 
bral symptom. A mild counter-irritant application to the outside of the 
throat is also useful j I have generally used sweet oil and spirits of harts- 
horn. When the conjunctival inflammation is acute and painful, it maybe 
relieved by lotions with simple warm water, milk and water, or sassafras- 
pith mucilage, alone or mixed with rose water. If the headache be very 
violent it can generally be relieved by the use of a laxative, by the occa- 
sional use of a mustard pediluvium, or of a sinapism to the nucha. When 
very severe and attended with much fever, it is safest to direct an appli- 
cation of leeches to the temples. 

The malignant form of the disease must be treated chiefly with stimu- 
lants and tonics. The most useful are wine and brandy, quinine, am- 
monia, capsicum, etc. Camphor and opium would be proper, were the 
case attended with severe nervous symptoms. The diet ought to be nutri- 
tious and digestible, and may consist of milk and bread, light broths, and 
beef tea or essence of beef. 

When local inflammations occur, they may be treated by a small venesec- 
tion if it can be borne, by a few cups or leeches, or by means of counter- 
irritants, of which the most suitable are mustard, spirits of turpentine, or 
ammonia. Blisters ought to be avoided, as they are very apt to occasion 
dangerous and even fatal sloughing. 

Treatment of the Complications. — Bronchitis, Pneumonia. — The 
mode of treatment of these complications must depend upon the stage at 
which they are developed, and upon the age and constitution of the subject. 
When they occur during the first stage, one of the most important points 



TREATMENT. 567 

in the treatment is to endeavor to favor the appearance of the eruption, 
and when in the second stage, and the eruption has retroceded wholly or 
in part, the same indication applies with equal force. When they appear 
during the third stage, they are to be treated without any regard to the 
eruption, but always with reference to the fact that the patient has just 
passed through an acute febrile disease, which must have weakened in 
some degree the vital powers. 

It may be stated in general terms, that the treatment proper for these 
local inflammations when they occur as primary affections, is proper also, 
with some reservations, under the circumstances we are now considering. 
Thus, bloodletting ought to be resorted to in some of the cases, but always 
with caution, since it is perfectly true that it cannot be used safely in 
secondary with the same freedom as in primary phlegmasise. In children 
under two years of age I have generally employed leeches, while in those 
over that age I have resorted to venesection, and in one case to 
venesection and leeching both. In all such cases I have used depletion 
with greater moderation than in primary cases, rarely applying more than 
a dozen American leeches at once, or taking more than four ounces of blood 
from the arm. Purgatives maybe used in conjunction with the depletion, 
always, however, bearing in mind in the choice of them, and in the doses, 
the disposition to gastro-intestinal irritation which is inherent to the 
malady. The antimonial preparations are also useful, given however, 
with greater care than usual. I generally employ antimonial wine with 
sweet nitre, or a solution of tartar emetic in simple water. Of the latter 
the thirtieth or fortieth of a grain for very young children, and the twen- 
tieth or thirtieth for those who are older, given every half hour or hour, 
is enough. If the quantity first given produces either sickness or diar- 
rhoea, it should be instantly suspended or very much reduced in strength. 
For children within the year, the syrup of ipecacuanha, in doses of two to 
five drops every hour or two, is, perhaps, preferable toantimonials. When 
in these cases the skin is at all coolish, or bathed with too considerable 
a perspiration, I have found the liquor ammoniae acetatis a very useful 
remedy. 

It is universally acknowledged that it is exceedingly important to assist 
nature in throwing out the rash, whenever these complications either pre- 
vent its formation, or cause its retrocession. The true mode of doing this 
is to cure or alleviate the internal inflammation, which is the cause of the 
difficulty. To attain this end the above plan of treatment ought to be in- 
stituted at once. At the same time, we may greatly assist the appearance 
of the eruption by a persevering employment of counter-irritants. The 
best of these is, I believe, mustard, and in some cases a warm bath. The 
mustard may be used in the form of plasters, poultices, or baths. My 
own plan in moderately severe cases, is to apply a mustard poultice to the 



568 MEASLES. 

interscapular space, and to make use of a mustard pediluvium, two or three 
times a day, while in severe and urgent attacks I direct the cataplasm and 
bath to be renewed every two or three hours, taking care, however, to 
apply the former alternately to the front and back of the chest, in order 
to avoid all possibility of too violent an action upon the skin ; the feet and 
limbs also ought to be carefully watched, to avoid the same danger. I 
have had occasion to observe the great efficacy of this unremitting em- 
ployment of revulsives, in several severe cases of bronchitis in young 
children. In some I have depended solely upon this treatment, and the 
use of small doses of ipecacuanha and spiritus Mindereri. In one parti- 
cularly, which occurred in a child eight months old, the attack came on in 
the first stage. On the fourth, fifth, and sixth days, the dyspnoea was ex- 
cessive, the respiration running up to 70 and 80 ; the pulse was frequent 
and small ; the skin pale and rather cool ; and the irritability and restless- 
ness very great. For a period of twenty-four hours, I used the poultices 
and foot-baths every two hours regularly, and gave internally the spiritus 
Mindereri at the same intervals. Nothing else was clone. On the sixth 
day, when one of the poultices was removed from the interscapular space, 
the integument beneath was observed to be covered with the measly 
stigmata, whilst there were none as yet on any other part of the surface. 
From this time the eruption came out freely, and the child recovered 
rapidly. 

The warm bath may be used under the same circumstances. It should 
be given with great care, the child being wrapped in a warm blanket the 
moment it is removed from the water, to prevent the least sensation of 
chilliness. It may either lie for a short time in the blanket, or be wiped 
dry beneath it, and then dressed. 

Cases of pure bronchitis have seemed to me to require less depletion 
than those of pneumonia. In some of the cases of bronchitis, there has 
been profuse secretion attended with extensive subcrepitant and mucous 
rales. In such instances I have found the internal use of the syrup or 
infusion of polygala seneka, with an occasional revulsive, very effectual. 

The diarrhoea which occurs so frequently seldom requires any treat- 
ment. Indeed, unless it indicates evident entero-colitis, or is accompa- 
nied by frequent mucous or bloody stools, and by pain and tenesmus, it 
is better not to interfere with it, beyond paying strict attention to the 
diet. When attended, however, with the symptoms just mentioned, it 
must be treated by astringents, by opium and ipecacuanha, and by the 
application of poultices to the abdomen. The seven cases that occurred 
to myself recovered under the use of laudanum enemata, given twice or 
three times a day, the strictest diet, and small doses of Dover's powder. 



TREATMENT. 569 

Laryngitis, as it occurs in most of the cases, needs but little treatment 
beyond careful avoidance of cold, the use of some mild nauseant, and 
revulsives to the neck. It is very seldom of a dangerous character. 
When, however, it assumes the character of pseudo-membranous croup, 
it must be treated with all activity, in the manner described in the article 
on that disease. In only two of the eight cases I have seen, did it 
appear at all threatening. One of these occurred in a boy ten years old, 
and came on in the first stage. The voice was very hoarse and difficult ; 
the cough was frequent, hoarse, and croupal, and preceded and followed 
by loud stridulous respiration. Fearing the formation of false membrane, 
though none was visible in the fauces, I ordered a venesection of four 
ounces, and doses of hive syrup every two hours, and finding at the end 
of six hours that there was no improvement, I had between three and 
four more ounces of blood taken from the throat by leeches. This was 
followed by slow but steady amendment of the symptoms ; the eruption 
came out well, and no further difficulty occurred. The second serious 
case occurred in a boy between one and two years old, also in the 
first stage. The symptoms were like those of the first case. They were 
treated by an application of leeches to the throat and by an emetic of 
alum, which relieved them very much, and they disappeared gradually. 
The eruption pursued its regular course. 

The cerebral symptoms which sometimes occur, must be treated diffe- 
rently in different periods of the disease. In the early stage, when they 
last but a short time and do not recur, they require nothing more than a 
warm bath, and the use of revulsives. If they continue to recur, or are 
followed by stupor or other cerebral symptoms, more energetic treatment 
becomes necessary. If the child is strong and hearty, it would be proper 
to resort to depletion, either by venesection, or by cups or leeches to the 
back of the neck or temples, and to purgatives, revulsives, and cold ap- 
plications to the head. When it does not seem proper to bleed, and when 
the heat is intense, it has been proposed to use cold lotions in the manner 
recommended in scarlatina. The evidence upon this point is not very 
conclusive, and as I have never used them, nor seen them used, nor in- 
deed seen any necessity for a resort to them, I can offer no opinion in 
regard to their use. 

I have met with five cases of convulsions in the first stage. One oc- 
curred in a boy five years old ; the convulsions were slight, lasted not 
more than ten or fifteen minutes, and were followed by no bad symptoms. 
The intelligence of the child returned very soon afterwards. The only 
remedy used was a warm bath. The other cases have already been 
described. 

When convulsions occur in the second or third stages, it is very impor- 



570 SMALL-POX. 

tant to ascertain whether they are not the result of some local disease. 
Two of the three cases that came under my notice accompanied violent 
attacks of bronchitis. The third was caused by congestion of the brain. 
Here the treatment must be directed against the local disease, if that can 
be detected. When, on the contrary, the convulsions seem to depend on 
nervous irritation, they may be treated with baths, revulsives, purgatives, 
and the careful administration of opium, as recommended by Sydenham, 
Copland, Rilliet and Barthez, and other authors, or of camphor, assafoe- 
tida, musk, or hyoscyamus. If accompanied by intense heat and great 
dryness of the skin, without local complications, cold or tepid lotions 
might also be tried. 



ARTICLE III. 



VARIOLA OR SMALL-POX. 



Definition ; Frequency ; Forms. — Variola is an epidemic and con- 
tagious disease, characterized by an initial fever, lasting from three to 
four days, and followed by an eruption at first papular, then vesicular, 
and afterwards pustular : the eruption attains maturity in from six to 
nine days, after which the pustules are converted by desiccation into 
scabs, which fall off between the fifteenth and twenty-fifth days. 

The frequency of the disease varies greatly in different years, because 
of its epidemic nature. It is far less common in childhood amongst the 
middle and upper classes of the community, than either measles or scarla- 
tina, in consequence, no doubt, of the attention paid to vaccination. I 
have seen but two cases of the disease under fifteen years of age, in the 
space of eleven years, whilst I have met with 185 of scarlatina, and 
upwards of 288 of measles. It prevails to a greater extent amongst the 
poor and destitute classes, who neglect the attention to vaccination neces- 
sary to preserve children from the disease. Dr. Condie (Dis. of Children, 
note, p. 86) states that 587 deaths under fifteen years of age, occurred 
from this disease in the ten years preceding 1845, while in the same 
period, there were 574 from measles, and 2154 from scarlatina. 

I shall describe two forms, the regular, including the distinct or dis- 
crete, and the confluent varieties of most writers, and the modified form 
or varioloid. I shall afterwards treat of the irregularities and complica- 
tions of the malady. 

Causes. — The principal cause of variola is universally acknowledged 



CAUSES — SYMPTOMS. 571 

to be contagion. It is generally admitted also that it is propagated at 
certain periods by epidemic influence. 

It is not clearly ascertained at what period of its course the disease 
first becomes contagious. Some assert that it is not until after suppura- 
tion is established. This is, however, to say the least, doubtful, and it 
is best, therefore, to take any precaution that may be necessary to prevent 
the extension of the disease from the moment that its real nature becomes 
apparent. There can be no doubt that the body may still impart the 
disease after death, and that clothes worn by the patient retain the con- 
tagious principle, unless freely exposed to the air, for days, months, and, 
it is said, even for years. 

One attack protects the constitution, in the great majority of cases, 
against subsequent contagion. When persons who have once had the 
disease contract it again, it almost always assumes a milder and much less 
dangerous form. 

The period of incubation, or the time elapsing between the reception of 
the poison and the beginning of the malady, varies generally between 
nine and twelve days. It may, however, be more or less than the periods 
just mentioned. 

Symptoms; Course; Duration. — Regular form of the disease. — I 
shall describe three stages of the disease : 1. That of the initial or erup- 
tive fever; 2. That of the progress and maturation of the eruption; and, 
3. That of decline or desiccation. In addition to these some writers 
make another stage, that of incubation, which includes the period between 
the introduction of the poison into the system, and the appearance of the 
first symptoms. This stage is seldom marked by symptoms sufficiently 
characteristic to enable us to detect the approaching disease, and in many 
instances is probably entirely unnoticed by the patient. 

The first stage, or that of initiatory fever, commences generally in chil- 
dren with pains in the bones and loins, and sometimes with rigors or 
chilliness, accompanied with headache, and soon followed by fever. 
Nausea and vomiting often exist from the first, or come on soon after the 
appearance of fever and headache. At the same time there is loss of 
appetite, thirst, and more or less obstinate constipation. The tongue is 
red at the point and edges ; one of the characteristic symptoms of this 
stage is pain in the loins, which generally dates from the first or second 
day, and though varying much in degree, is usually severe. The patients 
often complain also of abdominal pains, which seem to be colicky, and are 
referred either to the epigastric or umbilical region. 

Fever and headache are the most constant of all the prodromic symp- 
toms. The chilliness and rigors which frequently exist in adults, are not 
easily ascertained in the cases of children, and are therefore much less 



572 SMALL-POX. 

important. The fever varies greatly as to degree ; the heat of skin is 
generally considerable ; and may be acccompanied either with dryness or 
moisture. The pulse is commonly full and frequent. The headache is 
usually frontal and often very severe. In some cases there are strongly 
marked cerebral symptoms, consisting of excessive restlessness and irrita- 
bility, insomnia or somnolence, delirium, and even convulsions. 

The various symptoms just enumerated continue up to the moment 
when the eruption begins to make its appearance, which happens gene- 
rally in the course of the third day, though it may occur as early as the 
second, or as late as the fifth, sixth, or even seventh. In severe and con- 
fluent attacks, the eruption, as a general rule, begins earlier than in mild 
and distinct cases. 

Second stage, or that of eruption. — Some time in the course of the 
third day after the invasion of the attack, the eruption usually begins to 
make its appearance in the form of small, isolated, and rounded red 
specks, which soon become projecting and solid, or in other words are 
converted into papules. The papules are from a third to two-thirds of a 
line in diameter, of a more or less vivid red color, and disappear under 
pressure, to return immediately when the pressure is removed. The 
eruption shows itself first on the face, and generally about the chin and 
mouth, and then extends to the rest of the face, to the neck, trunk, limbs, 
feet, and hands. It sometimes happens, particularly in very young chil- 
dren, that the eruption appears first about the genital organs, whilst in 
other cases it is first observed on the lower part of the loins, or upon the 
thighs. The papules increase gradually in size and prominence for one, 
two, or three days, and, as a general rule, some time in the course of the 
second day of the eruption, undergo a change into vesicles. This change 
takes place by the formation on the top of each papule, of a little trans- 
parent elevation of the cuticle, beneath which is deposited a drop of 
serosity. The conversion of the papules into vesicles occurs first on the 
face, and then on the neck, trunk, and extremities. The vesicles are at 
first smaller than the papules, and acuminated in shape, but as they grow 
larger, become gradually flattened and depressed in the centre ; after a 
time they cover the whole papule, and before long exceed it in size. As 
these changes take place, the fluid they contain loses its transparency, 
becomes opaline, and by degrees the vesicles are transformed into pus- 
tules, which constitutes the third stage of the eruption or that of suppu- 
ration. 

The pocks are more or less numerous, according to the extent and 
severity of the eruption. When scattered over the surface so as not to 
touch at their edges, the disease is said to be distinct ; when, on the con- 
trary, so numerous as to come into contact and run together, it is called 



SYMPTOMS. 573 

confluent. Of these two varieties, the latter is necessarily more severe 
and dangerous than the former, in consequence of the greater extent of 
tegumentary surface inflamed. During the various changes the vesicles 
undergo, they are surrounded by small, inflamed areolae, which differ 
in appearance according to the number of the vesicles. In cases of 
the distinct form, in which the eruption is sparse, so that the pocks are 
widely separated, the areola fade gradually into the natural color of the 
skin, at the distance of a third or two-thirds of a line or more from the 
base of the vesicles, whilst in those in which the eruption is more abun- 
dant, they run together, so that the spaces between the pocks are of a 
more or less bright red color. In confluent attacks, again, the areolae are 
more or less imperfect, according to the manner in which the vesicles are 
grouped together. 

The change of the vesicles into pustules takes place generally from the 
fourth to the sixth day of the eruption. During this process the fluid of 
the pocks becomes more and more opaque, whitish, and at length assumes 
a yellowish color, being in fact converted from serosity into pus. At the 
same time the pocks become larger, begin to distend, and as they approach 
complete maturation, gradually lose their umbilicated shape and become 
convex on the surface. The formation of the pustules follows the same 
course as did the vesicles, beginning on the face and extending thence to 
the neck, trunk, and extremities. The areolae that have just been de- 
scribed as existing during the vesicular stage of the disease, continue 
during the early part of the stage of pustulation, but decline towards its 
termination, assuming as they disappear a purple tint. The number of 
pustules is in proportion of course to that of the vesicles, but from the 
increase in size of the pocks during the changes from papules into vesicles 
and pustules, the eruption, when at its height, seems to be greatly more 
extensive than would have seemed probable at the beginning of the first 
stage. As a general rule the pocks are most numerous on the face, and 
after that part on the neck and limbs. On the trunk the eruption is 
always much less abundant than on other parts of the body, and even 
when confluent in the highest degree on the face and neck, it is gene- 
rally so only in patches on the limbs, while it is distinct on the thorax 
and abdomen. 

Simultaneously with the eruption upon the skin, there occurs one also 
upon the mucous membranes, particularly those of the mouth, nasal pas- 
sages, fauces, eyelids, and sometimes of the prepuce and vulva. It be- 
gins with more or less vivid redness of the membrane followed by the 
production of little elevations, the real nature of which, whether papular 
or vesicular, seems not to be clearly determined. About the second or 
third day these red elevations assume the appearance of small, whitish, 



574 SMALL-POX. 

rounded, not umbilicated pseudo-membranous points, which last generally 
about five days, and are then detached, leaving usually a little ulceration 
or erosion, which heals without leaving a cicatrix. 

A short time after the appearance of the pustules in the mouth and 
throat, a true inflammation of the mucous membrane of those parts takes 
place. When the gums are inflamed they become swelled, red, and 
spongy, and are dotted over with white pseudo-membranous points of a 
rounded shape. Sometimes the velum pendulum, and more rarely the 
tongue, present the same white points, with redness and injection of the 
membrane between. In most of the cases there is also partial or general 
inflammation of the pharynx, which occurs subsequently to the formation 
of the variolous pustules. The existence of this inflammation is denoted 
by more or less severe sore throat, attended with difficulty of swallowing, 
and with swelling and tenderness of the submaxillary glands. When 
the mucous eruption extends to the larynx, as often happens, there is 
pain in that part ; the voice becomes hoarse or whispering, and there is 
a hoarse, laryngeal, smothered cough. The pharyngo-laryngitis just de- 
scribed occurs generally between the third and sixth days of the eruption, 
and ceases about the eighth or thirteenth. In some instances it does not 
exist at all or only to a slight extent. 

During the eruption there is more or less inflammation and swelling of 
the subcutaneous cellular tissue, the degree of which depends on the ex- 
tent of the eruption. The skin becomes tense, red, shining, and elastic 
under the finger, and more or less hot and painful. . The swelling is 
greatest upon the face, where it commences about the fourth or fifth day 
of the eruption, and goes on increasing for five or six days, occasioning 
much pain, stiffness, and inconvenience to the child. The swelling di- 
minishes when desiccation begins, and ceases entirely as the latter is 
accomplished. 

It is important to study carefully the general symptoms of the second 
stage. The fever which existed during the initial stage generally con- 
tinues during the first day or two or three days of the eruption. When, 
however, the papules are fully thrown out, the fever subsides or disap- 
pears entirely, so that the pulse falls from 100, 120, or 140 beats, to 100, 
80, 76, or 74, and the heat of skin diminishes at the same time. The 
child remains without fever usually throughout the vesicular period of the 
eruption, that is to say, until the fourth, fifth, or sixth day ; during which 
time the appetite sometimes returns, sleep is tranquil and quiet, and the 
patient is in most respects well and comfortable. 

About the fifth or sixth day of the eruption, at which time the matu- 
ration of the pustules is nearly completed on the face, and that process 
is commencing on the extremities, a new fever, to which the technical 



SYMPTOMS. 575 

term secondary fever is applied, makes its appearance. The pulse rises 
again to 88, 100, 120, and 140, and becomes strong, hard, and full, whilst 
the skin is hot and dry. After continuing for some days the secondary 
fever diminishes when the suppuration is fully established, and disappears 
about the time that desiccation is nearly completed on the lace, and has 
commenced upon the limbs. It ceases generally, therefore, about the 
ninth or eleventh day, having lasted between four and six days. This 
attack of fever is evidently the consequence of the suppurative stage of 
the disease, or of the conversion of the vesicles into pustules. 

Towards the termination of the second stage, at the very height of the 
disease, when the pustules begin to break and discharge their contents, 
the patient exhales a peculiar, disagreeable, and fetid odor, which is 
somewhat characteristic of the disease. 

The third or declining stage, is that of the desiccation or drying of the 
pustules and their desquamation. The desiccation commences generally 
between the sixth and ninth days, and terminates between the tenth and 
fourteenth. The formation of the crusts begins upon the face and extends 
thence to the neck and limbs. It does not reach the limbs usually until 
about two or four days after it had commenced on the face. The mode 
in which the drying of the pustules takes place is not the same in all. 
In some a dark point is formed in the centre which gradually extends and 
converts the whole pustule into a hard crust ; in others the whole surface 
dries at the same time; while in others again, the epidermis gives way 
and allows the contained fluid to escape, which then hardens into yellow- 
ish, irregular crusts, which become brown before they fall off. Some of 
the pustules, particularly those upon the arms and legs, do not form scabs 
at all, but shrink away from the absorption of their fluid, leaving behind 
nothing but pellicles of cuticle which fall off by desquamation. 

The desquamation or falling of the crusts begins from the eleventh to 
the sixteenth, and ends somewhere between the nineteenth, twenty-fifth, 
and even fortieth days of the eruption. When the scabs fall off the 
appearances presented by the skin beneath vary in different cases. In 
some a true ulceration and loss of substance of the derm has taken place, 
which gives all the characters of a suppurating ulcer when desquamation 
has begun early in the disease ; when that process occurs at a later period, 
the ulcer is found to be dry and cicatrized. In both these forms of des- 
quamation, the cicatrices form little pits or depressions, which remain 
during life. In other instances the fall of the scabs leaves red and ex- 
coriated surfaces which are on a level with the surrounding skin, but which 
soon dry, leaving blotches of a reddish-brown color, that do not disappear 
entirely for months. No cicatrices remain when desquamation takes place 
in this manner. In a third series of cases the crusts do not fall until the 



576 SYMPTOMS. 

surfaces beneath have completely cicatrized, and the only traces left behind 
are more or less deeply tinted reddish spots, with occasional slight furfu- 
raceous exfoliation of the cuticle, all of which disappear entirely after a 
time without leaving pits or cicatrices. 

To conclude the account of the symptoms of the disease, I have a few 
words to say in regard to the condition of some of the important organs 
throughout the course of the malady. 

The tongue presents no appearances peculiar to the disease, other than 
the eruption already described. It is generally moist, more or less furred, 
and either pale or red in color. The abdomen usually remains soft and 
undistended, though in some instances it is slightly tumid and hard, with 
occasional pains in the epigastric, umbilical, or iliac regions ; in simple 
cases, the latter symptoms rarely last more than a short time, and when 
otherwise they are almost always the sign of some complication. The 
constipation which exists during the initiatory stage generally continues 
throughout the disease, though in some instances a slight diarrhoea occurs 
about the end of the first or second week, after which the bowels return 
to their natural condition. If severe diarrhoea should make its appear- 
ance, it is almost always the sign of a dangerous complication. The 
nausea and vomiting which are so often present during the prodromic 
stage, cease after the appearance of the eruption, and recur only in rare 
cases, or in consequence of some complication. The appetite is almost 
always lost during the course of the disease, though it sometimes returns 
in the period between the termination of the initial and the commence- 
ment of the secondary fever ; thirst is acute as a general rule ; and more 
or less so, according to the violence of the fever. 

The strength of the child is not," as a general rule, greatly diminished, 
except in severe and dangerous cases. Restlessness , irritability, crying, 
and delirium, which are of such frequent occurrence in the febrile dis- 
eases of children, are not usually very strongly marked in regular cases 
of variola. They exist, but it is to a moderate extent only. In severe, 
irregular, and confluent cases, on the contrary, restlessness, crying, and 
delirium, are present in a very high degree, either towards the termina- 
tion of the attack, or throughout its course, and they are then of very 
bad augury. 

I shall here conclude the history of the symptoms of the regular form 
of the disease. I have not attempted a separate account of the distinct 
and confluent cases, believing them to be merely different degrees of the 
same affection ; the latter being much more severe and dangerous, from 
their greater intensity, than the former. I will merely remark that all 
the symptoms are very severe in confluent cases, particularly the fever 
and those which indicate disorder of the nervous system. 



IRREGULARITIES. 577 



I shall proceed next to a description of some of the irregularities of 
the disease, or, as expressed by some writers, of irregular or anormal 
variola. I would remark in the first place that a large number of the 
cases that have been called confluent, ought rather to be called irregular, 
since many of the symptoms detailed as belonging to that form of the 
affection, depend, not upon the confluent nature of the eruption, but upon 
the existence of some irregularities in its characters, entirely independent 
of the confluence or running together of the pustules. 

The first or initial stage of irregular variola may be either longer or 
shorter than in the regular form. As a general rule, the symptoms of 
this stage resemble very closely those of the regular form, when the 
attack occurs in a child previously in good health ; whilst in secondary 
attacks they present differences which are more or less strongly marked. 
The most important of these are the greater infrequency of headache, 
vomiting, and of the lumbar pains ; the presence of diarrhoea rather than 
constipation ; the greater frequency of sleeplessness, oppression, and rest- 
lessness ; and, as a general rule, the earlier appearance of the eruption. 

The second or eruptive stage generally passes through its periods with 
much greater rapidity, so that the conversion of the papules into vesicles 
occurs as early as the first or second day, and that of the vesicles into 
pustules, between the second and fourth days. In some few cases, on the 
contrary, the eruption is retarded, and the papules may remain unchanged 
as late even as the fifth or sixth day. The progress of the eruption is so 
irregular sometimes that there may exist upon the same surface, papules, 
vesicles, pustules, and scabs. 

The appearances presented by the eruption often differ widely from 
those which have been described as characteristic of the regular disease. 
The papules may be pale, irregular, uneven, and destitute of areolae ; and 
when this happens, the vesicles and pustules which follow usually pre- 
sent the same peculiarities. In other instances the papules and areolae 
are of a purple-red color, and the vesicles, instead of being transparent 
or whitish, are also reddish, and appear to be filled with a bloody serum. 
The pustules in these cases also contain a sanguinolent fluid, and when 
broken, their contents escape and form bloody scabs. In this variety of 
the disease, which is called hemorrhagic, the papules and vesicles are very 
small, are developed slowly, and remain flat and undistended, as a general 
rule, whilst in a few cases, they are of a larger size, but remain almost 
always flattened in shape and unfilled. The scabs, when they form, are 
thin, soft, easily detached, and leave beneath bleeding surfaces and 
scarred pits. 

The fever of the initial stage rarely subsides in irregular variola, upon 
the appearance of the eruption, as it does in the regular disease ; but, on 

37 



578 SMALL -POX. 



efore, 



■ 



the contrary, usually goes on augmenting. The distinction, therefor 
into primary and secondary fever does not properly exist. Sometimes, 
however, a notable increase of fever does take place at the period when 
the vesicular passes into the pustular stage of the eruption. The fever 
is usually more violent in the form of the disease under consideration, 
than in regular attacks, the pulse being full and large, and rising as high 
as 160. In fatal cases it becomes small towards the termination. The 
skin is generally very hot and dry. 

The appearances of the tongue, condition of the abdomen, appetite, 
thirst, and nervous symptoms, are of the same character as in the regular 
form, except that the signs which they present are more severe and un 
favorable, particularly the delirium, agitation, and cries. 

Varioloid, or Modified Small-pox. — This is a term now usually 
applied to the modified form of the disease, as it occurs in individuals 
who have been vaccinated, or who have already had the natural or 
inoculated disease. 

The symptoms of this form of variola are, in general, the same as those 
of the regular disease, the only difference being in their greater mildness 
and shorter duration. The attack usually begins with slight fever, head- 
ache, languor, and sometimes constipation, which are followed, in two or 
three days, by the eruption. The vomiting, lumbar pains, and different 
nervous symptoms which exist in regular variola are not often present, 
or, if so, in a very slight degree. The eruption consists of papules like 
those of true small-pox, but usually they are few in number, and entirely 
distinct in their arrangement. The prodromic fever and other symptoms 
subside completely upon the appearance of the eruption, and the child 
often seems perfectly well. 

The progress and character of the eruption are very similar to those 
of the regular form of the disease, with the exception that the changes 
are more rapidly effected, and, as a consequence, the duration of the attack 
is rendered by so much the shorter. The papules are converted into 
vesicles at a much earlier period, — as early as the first or second day. 
The vesicles soon assume a whitish, opaline appearance, become umbili- 
cated, and in the course of the second or third day begin to change into 
pustules. The suppurative stage of the eruption, or maturation, is seldom 
accompanied by the same marked secondary fever as in the regular dis- 
ease. When the fever does occur, it is generally very moderate, consisting 
merely in slight acceleration of the pulse and a little increased heat of 
skin, and in one or two days disappears entirely. The pustules do not 
fill usually so well as in regular variola, and not unfrequently their con- 
tents are rather sero-purulent, than purulent, in the proper sense of the 
term. The third stage occurs earlier and goes through its periods more 



COMPLICATIONS — LESIONS. 579 

rapidly than in true small-pox ; desiccation soon takes place, is speedily 
finished, and the falling of the scabs, which begins as early as the eighth 
day of the eruption, is usually completed about the twelfth or fourteenth. 
After desquamation is completed, the only traces of the disease left are 
reddish spots or blotches, which disappear after a time without leaving 
cicatrices. The whole duration of the attack is generally from ten to 
twenty days. 

Complications. — The most frequent and important complications of 
variola in children, are inflammations of the mucous membrane of the 
lower half of the intestinal tube, ophthalmia, otitis, and different hemor- 
rhages. In a smaller number of cases, attacks of bronchitis, pneumonia, 
anasarca, articular inflammations, subcutaneous abscesses, simple and 
pseudo-membranous coryza, angina, and laryngitis, and other eruptive 
diseases, occur at different periods of the malady. 

Meningitis and encephalitis are very rare, so much so, that not a single 
instance occurred out of 112 fatal cases of the disease in the Children's 
Hospital, at Paris. 

It is impossible for me, for want of space, to attempt a description of 
the various symptoms of the different complications just enumerated. 
Having mentioned the possibility and probability of their occurrence, I 
must leave the reader with the advice always to suspect the existence or 
approach of some one of them, when the symptoms, in any case, differ 
much from those which have been described as characteristic of the regular 
form. 

Anatomical Lesions. — The characteristic lesions of small-pox are a 
certain deteriorated state of the blood, congestion of all the organs, and 
the inflammation of the skin and mucous membranes constituting the 
eruption. The blood is found to be entirely liquid and serous, and of a 
dark color ; or if coagula exist, they are small, soft, and very dark in 
color. The exceptions to this rule are those in which some acute and 
severe inflammation exists, under which circumstances the dissolved state 
of the blood is less marked, and fully formed coagula are more abundant. 
The congestion referred to affects almost the whole system. The muscles 
are firm and of a deep red color ; the membranes of the brain are strongly 
injected, the sinuses are filled with blood, and the cerebral substance pre- 
sents numerous red points or dots. The vessels of the lungs contain a 
large quantity of blood, and the liver, spleen, and kidneys, are all deeply 
congested. 

The condition of the mucous membranes is important. The pharynx, 
larynx, and trachea, present an eruption, or simple inflammation with- 
out eruption. The eruption exists under the aspect of small, circular, 
thin, and whitish pseudo-membranous points, scattered over the mucous 



580 SMALL-POX. 

tissue, and slightly adherent to it, beneath which that tissue is often 
observed to be red and inflamed. At a more advanced degree, and 
in severer cases, the false membranes have disappeared, and in their 
places we find circular ulcerations, which are either superficial, or they 
penetrate the tissue of the mucous coat and rest upon the muscular, or 
even pierce that and reach to the cartilaginous tissue beneath. In addi- 
tion to these lesions are found inflammation of the mucous tissue with its 
consequences, redness, softening, thickening, and extensive deposits of 
false membranes, quite distinct from the appearances above described as 
characteristic of the eruption upon these tissues. 

It has been a contested point whether a true vesicular or pustular erup- 
tion ever exists upon the mucous lining of the stomach and intestines. 
The general opinion appears now to be, however, that the changes observed 
in these organs cannot be ascribed to the formation either of vesicles or 
pustules. The appearances that have led some observers to consider them 
as the result of a proper eruption are the following. The follicles at the 
commencement and termination of the small intestines, and in rarer cases, 
of the large intestine also, present an abnormal degree of development, 
appearing in the form of small, hemispherical or pointed, and sometimes 
flattened projections, on which there often exists a dark, and sometimes 
depressed central point. At the same time the plaques of Peyer are often 
enlarged, more projecting than usual, softened, and red. 

The anatomy of the variolous pock is important and interesting. 
When a vesicle is opened soon after its formation, it is found to contain 
nothing but a little serosity which is perfectly limpid and alkaline, while 
the skin beneath is red, softened, and moist. The umbilicated character 
depends on a filiform adhesion between the centre of the pock and the 
surface of the skin beneath. This adhesion is broken, when, at a later 
period, the pustule becomes globose in shape. About the period of the 
conversion of the vesicles into pustules, or very soon after the formation 
of the latter, the cavity of the pock will be found to contain a false mem- 
brane, which is of an opaque white color, soft and friable in its texture, 
and seated upon the derm in small isolated points. After a time these 
points enlarge, and meeting, unite, and form a soft pseudo-membranous 
disk, uneven upon its surface, and which either fills the pock completely, 
or is covered at first with serosity and afterwards with pus. This false 
membrane is secreted originally by the true skin. At a somewhat later 
period it forms a strong adhesion to the inner surface of the cuticle, while 
still later in the progress of the pock, it becomes detached from the cuticle, 
and remains loose and free in the cavity of the pustule, surrounded by 
the fluid contents of the latter. 

Diagnosis. — The most important point in the diagnosis of variola, is 



DIAGNOSIS — PROGNOSIS. 581 

its recognition during the prodromic or initial stage. The only symptoms 
that can be depended upon as indicating with any considerable probability 
the approach of the disease, are the simultaneous existence of fever, con- 
stipation, bilious vomiting, and severe pains in the back, in a child not 
previously vaccinated, and in whom there is no more probable mode of 
accounting for the symptoms enumerated. If, in addition to these cir- 
cumstances, the disease be extensively prevalent at the time, and still 
more, if the child has been exposed to the contagion of the malady, the 
diagnosis becomes almost certain. After the eruption makes its appear- 
ance the diagnosis is seldom doubtful. There may be some doubt for the 
first few hours, but soon the enlargement of the papules, the subsidence 
of the fever, and then the change into vesicles, remove all uncertainty as 
to its real nature. 

Prognosis. — The prognosis of variola must depend very much upon 
the form which it assumes. The regular form of the disease generally 
terminates favorably unless some complication happens to occur, in which 
case the danger to life is greatly augmented. It is generally stated also 
that the distinct is much more favorable than the confluent form of the 
affection. MM. Rilliet and Barthez say, however, that all the cases of 
the simple (uncomplicated) confluent disease which they met with reco- 
vered. Irregular variola, on the contrary, is fatal in a large proportion 
of the cases. The authors just quoted state that only three recovered out 
of thirty-nine that came under their observation. 

The varioloid disease is very rarely fatal. 

The favorable symptoms in any case of variola are the occurrence of 
the disease in children previously in good health ; the absence of any 
violent nervous symptoms during the initial stage ; a proper duration of 
the first stage ; and subsidence of the fever after the appearance of the 
eruption. When, in addition to these circumstances, the secondary fever 
is not too violent, and no complication arises, there is but little doubt that 
the patient will recover. 

The unfavorable symptoms are the existence of severe nervous symp- 
toms during the first stage ; the occurrence of a thick and abundant erup- 
tion upon the face, indicating a probably confluent case ; continuation of 
the fever after the appearance of the eruption, or a merely slight subsi- 
dence of it; delirium and other nervous symptoms during the secondary 
fever ; and any irregularity in the appearance of the eruption, as paleness 
instead of the usual red color, a livid or purplish color of the pustule, 
imperfect development of the pocks, or their sudden shrinking without 
diminution of the general symptoms. It is scarcely necessary to say that 
many of these symptoms are indicative of the existence or threatened 
production of some complication, upon the nature of which must depend, 



582 SMALL -POX. 

after all, in great measure, our prognosis. The complications most apt 
to occur have already been considered in a previous article. 

Treatment. — I shall begin my remarks upon the treatment of the 
disease with the following quotation from Dr. Gregory (Tweedie's Lib. of 
Pract. Med. , Am. ed., vol. i. p. 332). "Before entering on the curative 
treatment of small-pox, therefore, it will be proper to recall to remem- 
brance the peculiar nature of the disorder. It is a fever which relieves 
itself by superficial eruption. That eruption, even when too copious, 
cannot be diminished or checked in its progress by any effort of art ; 

when moderate it requires not the interference of the physician." 

" Heroic remedies are here wholly inapplicable, and the great object of 
art is simply to place the system under the most favorable circumstances 
for effecting what the old physicians called the concoction and elimination 
of the morbid humors." 

The treatment of simple, uncomplicated small-pox ought, unless the 
attack be confluent, to be of the mildest character. Rest in bed, low 
diet, cooling drinks, some gentle laxative, and an occasional foot-bath during 
the first stage, are all that is required in most cases. When, however, 
the fever is considerable, and the child restless and complaining, we may 
add to these means some diaphoretic, as the saline or effervescing mixture, 
with small doses of sweet spirits of nitre, or spiritus Mindereri ; or we 
may direct very minute doses of tartar emetic, from g^th to g^th of a 
grain for a child four years old, to be repeated every hour or two hours, 
or from one to three drops of the antimonial wine, with five or ten of 
sweet nitre, for a child of the same age, every two hours. Should either 
of these produce much vomiting, or any action upon the bowels, they 
must be suspended. If the fever be violent, either during the initial 
stage, or later in the attack, with a full strong pulse, great heat and 
swelling of the skin, severe headache, or signs of congestion of the in- 
ternal organs, it will be proper to bleed, either generally or locally. 
General bleeding is preferable as a general rule, unless there be some 
local determination, in which event local depletion may be substituted ; 
but even here venesection had better be resorted to in many cases, as 
more effectual and less annoying to the child than either cups or leeches. 
The amount of blood to be taken must depend on the age, constitution, 
and present strength of the patient. Having regard to the nature of the 
disease, it is best always to bleed less freely than in acute local affections. 
Under the circumstances just supposed, we are advised by Dr. Gregory 
to make use of purgative medicines every day. MM. Billiet and Barthez, 
on the contrary, oppose their employment, as likely to occasion some 
serious intestinal lesions, and advise the use merely of mild laxatives or 
enemata to an extent sufficient to keep the bowels soluble. 



TREATMENT. 583 

When the eruption comes out slowly and tardily, remaining for an 
unusual length of time in the papular state, or forming small and flat- 
tened vesicles, the pulse being at the same time frequent and undeveloped, 
we may hasten its appearance by the use of some warm diaphoretic infu- 
sion, as balm or sweet-marjoram tea, with spiritus Mindereri, by putting 
additional covering upon the child, and by the employment of warm 
baths, of mustard pediluvia, and of mustard poultices to the epigastrium. 

Dr. Gregory advises the employment of nourishing diet and gently 
cordial medicines, when the pustulation is profuse over the whole body. 
When the period of secondary fever is accompanied with symptoms of 
extreme debility, as feeble pulse, brownish tongue, coldness of the skin, 
typhoid expression of the countenance, subsultus tendinum, and general 
tremors, the treatment must consist in the use of nutritious diet, and of 
stimulants, as wine and brandy, carbonate of ammonia, and quinine or 
compound infusion of cinchona. Camphor, administered in doses suffi- 
cient to allay the disturbance of the nervous system, is an excellent adju- 
vant to the stimulants just mentioned. In cases of hemorrhagic variola, 
the above stimulating treatment must be made use of, in connexion with 
the use of bark or quinine in large doses, and of some of the mineral acids. 
The quinine ought to be given in doses of a grain every hour or two, so 
that from six to ten grains may be taken every day. 

Treatment of the Complications. — It may be stated, in general 
terms, that the treatment for the different complications is the same as that 
which is proper for them when they exist as idiopathic affections, with, 
however, the modifications rendered necessary by the nature of the gene- 
ral disorder. Thus, acute inflammation must be treated by antiphlo- 
gistics, used, however, with great care and reserve, in consideration of 
the length of time during which the patient must be sick, and the neces- 
sity there is for preserving his strength and maintaining a proper crasis 
of the blood, in order that he may be enabled to carry on the various 
changes in the disease requisite to effect a return to health. These 
remarks apply particularly to angina, laryngitis, bronchitis, pneumonia, 
entero-colitis, and ophthalmia. When the acute affection is only of 
moderate extent and severity, it is best, except in the case of intestinal 
inflammations, to depend upon a moderate employment of cathartics, of 
small doses of the antimonials in conjunction with diaphoretics, of gentle 
counter-irritants, and, when necessary, to make small detractions of blood 
by leeches. Nevertheless, it is undoubtedly proper, when the acute 
disease is severe and extensive, the child strong and vigorous in constitu- 
tion and present health, the pulse full and strong, and the skin hot and 
red, to resort to general bleeding. 

The treatment of the ophthalmia which so often threatens, and some- 



584 SMALL-POX. 

times occasions great or irreparable injury to the eye, must be of the 
kind just recommended. In this complication the local treatment is 
exceedingly important. When ulcerations occur upon the cornea, they 
ought to be touched, if this be practicable, with solid nitrate of silver, 
sharpened to a point, or with a fine camel's hair pencil which has been 
moistened and rubbed over the caustic to insure a caustic solution. 
When it is impossible to apply the solid caustic or the brush, we must 
resort to some collyrium. This may consist of a solution of nitrate of silver, 
a grain to the ounce, or of one or two grains of sulphate of zinc, with 
twenty or thirty drops of wine of opium, dissolved in an ounce of rose-water, 
two or three drops of either of which are to be introduced into the eye 
morning and evening. When the first solution is used, its strength 
should be increased after a few days to a grain and a half or two grains, 
or even more, to the ounce of water. 

The complication of entero-colitis must be treated by the most careful 
attention to diet, the use of warm poultices to the abdomen, of emollient 
and anodyne injections, the internal administration of astringents and 
small doses of opiates, and when absolutely necessary, by small detractions 
of blood by leeches. When the diarrhoea is severe, and the stools mucous 
or bloody, we may use with advantage the nitrate of silver internally or 
by enema, in the manner directed in the article upon entero-colitis. 

The treatment of the convalescence from variola is important. The 
same rules apply to it as to other infantile and children's diseases. 

Before terminating my remarks upon the subject of small-pox, it will 
be proper to give some account of the treatment of the eruption which 
has been recommended and practised, with a view to prevent the scarring 
and disfiguration which so often result from the ravages of the disease. 
Of the different means which have been employed with this view, there 
are two which are almost exclusively relied upon at present. One is to 
cauterize the pustules with nitrate of silver, and the other to make a 
mercurial application upon the part where it is desirable to cause the 
abortion of the eruption. The cauterization has been performed in two 
modes ; by the application of the caustic to each pustule separately, or to 
masses of the eruption. It appears, however, that the first-named method 
is much the most preferable. To succeed perfectly, it is necessary to 
touch the derm forming the base of the pustule ; so that the best plan is 
to remove or lift up a portion of the top of the vesicle with a lancet, and 
then to introduce into its interior the sharpened point of a stick of 
caustic. This operation is only certainly successful when performed on 
the first or second day of the eruption, though MM. Killiet and Barthez 
have known it to answer as late as the third and fourth, or even fifth day. 
The process of cauterization is productive of acute pain, but does not 



TREATMENT. 585 

increase the local inflammation, according to the authors just quoted, at 
least when applied to a small number of the pocks. They state that 
when applied to the pustules seated upon the edges of the eyelids, it is 
almost incredible to behold how great is the diminution of the oedema of 
those parts in a single day. The conclusion of these gentlemen is, that 
individual cauterization of the pustules with nitrate of silver does cer- 
tainly cause them, as well as the surrounding tumefaction, to abort, and 
prevents them from leaving cicatrices. 

The other method which has been employed to cause the abortion of 
the pustules and thus prevent disfiguration is, as has been stated, the 
application of some mercurial preparation. The effects of this treatment 
are said to be an almost certain arrest of the development of the eruption, 
when it is used from the first or second, or not after the third day ; the 
vesicles and pustules remaining small and isolated, and not assuming, or 
else soon losing the umbilicated character. "When applied early, while 
there are as yet but few vesicles formed, it prevents the development of 
new ones, and diminishes the accompanying swelling and soreness. 
When the application is removed on the seventh or eighth day. it is found 
that desiccation has occurred imperfectly, the surface presenting small 
soft scabs, or little whitish, soft elevations, consisting of the pseudo- 
membranous substance situated between the true skin and the new epi- 
dermis, the old cuticle having generally peeled off with the plaster. In 
some places a light rose-colored surface alone remains. 

In regard to the success of this treatment in preventing disfiguration, 
I may quote the statement of MM. Rilliet and Barthez, that none of the 
patients upon whom they saw it tried presented any cicatrices, though 
several had had confluent small-pox. which pursued its usual course on 
the parts not covered by the application. Dr. Stewardson, of this city, 
made a considerable number of trials of this treatment at the small-pox 
hospital of this city in 1841-42. He gives his conclusions in the fol- 
lowing words (Am. Journ. Med. Sci., January, 1843, p. 86-7) : " From 
these experiments, it seems pretty evident that the mercurial plaster has 
a decided influence upon the small-pox pustules, preventing more or less 
completely their perfect maturation, and diminishing the concomitant 
swelling and soreness, the process of desiccation being completed without 
the formation of thick scabs, and the resulting cicatrices less marked than 
when the process of suppuration was left to pursue its natural course." 

u That by its use pitting may be entirely prevented, or the 

mortality from small-pox materially lessened, seems to me very doubtful, 
although had all the precautions above-mentioned been taken, it is not 
improbable that the effects would have been still more decided/' 

The use of the mercurial application is attended with some inconve- 



586 SMALL-POX. 

nience. In the first place it is difficult to keep it accurately applied, 
particularly in children, in consequence of the unpleasant sensations it 
occasions. In the second place, it not very unfrequently, according to 
MM. Rilliet and Barthez, produces an eruption of hydrargyriasis or mer- 
curial roseola, in about eight or fourteen days after the variolous erup- 
tion, or four or ten after the application of the remedy. Rayer, however, 
states this effect to be a rare one. 

Dr. Stewardson says that he thinks no apprehension need be felt as to 
constitutional affection from the mercury, for scarcely ever were the gums 
even touched. I may state, however, that when in Paris in 1840, I saw 
this effect produced in a young girl at the Children's Hospital. 

The method of its application is different in different hands. The 
French generally employ the emplastrum de Vigo cum mercurio. Dr. 
Stewardson prefers the strong mercurial ointment, either pure or rubbed 
down with an equal bulk of lard, spread upon a piece of thick muslin. 
The muslin is to be cut into the shape of a mask, with apertures for the 
eyes, nose, and mouth. It is secured upon the face by means of strings 
attached to its margin and tied across the back of the head and neck. It 
is important always for the success of the measure, that the application 
should be kept in close contact with the skin. To insure this Dr. S, 
employed a separate piece of muslin for the nose, which is the part most 
difficult to fit. With the same view the French authors recommend that 
the plaster should be cut into pieces to suit the different portions of the 
face, making one for the forehead, and others for the cheeks, sides and 
back of the nose, and upper and lower lips. Any spaces that may 
remain are to be covered with other portions of the plaster, and the 
whole secured with strips of diachylon. On account of the difficulty of 
applying the mercurial plaster, the following ointment was composed by 
the apothecary of the Children's Hospital at Paris, and has been found to 
answer very well : 

R. — Mercurial ointment, 24 parts, 

Yellow wax, 10 parts, 

Black pitch, 6 parts. — Mix. 

The application ought to be confined to the face, as that is the part 
which it is most important to save from disfiguration, and as it is better 
not to use it upon a larger surface than necessary, lest it might occasion 
the mercurial roseola, or possibly salivation. As a general rule, four or 
five days are sufficient, according to G-uersant and Blache, to leave it in 
contact with the skin, in order to avoid the bad effects just referred to. 



VACCINE DISEASE. 587 



ARTICLE IV. 



VACCINE DISEASE. 



Definition ; Synonymes ; History — The vaccine disease is an eruption 
produced originally in the human subject by inoculation with the virus 
of a certain disease developed upon the udder of the cow. It is suscep- 
tible of propagation from individual to individual by inoculation, but is 
contagious in no other way, and it possesses the invaluable quality of pro- 
tecting, with very great, though not with absolute certainty, those through 
whom it has passed, against small-pox. 

Besides the name given above it is known by the titles of cow-pox, 
kine-pock, vaccina, and vaccinia. 

Some knowledge of the nature of the vaccine disease, and of the power 
it possesses to protect the human constitution against small-pox, has been 
found to have existed in different parts of the world, but there can be no 
doubt that it is to the genius and patient research of Dr. Jenner that we 
owe the inestimable blessing of vaccination, since it was by him that its 
marvellous virtue was first demonstrated and proclaimed to the world. 
Dr. Jenner learned, at an early period of his life, that there existed a 
popular belief in Gloucestershire, in England, that persons who had con- 
tracted a peculiar vesicular disease from the udder of the cow were thereby 
protected from the attack of small-pox. Becoming convinced, by a long 
course of patient observation, that this belief was founded in fact, he de- 
termined at last to try whether the disease might not be transmitted from 
one person to another, and thus increase immeasurably the utility of this 
wonderful protective means. On the 14th of May, 1796, accordingly, he 
vaccinated a child eight years old with matter taken from the hands of a 
milker who had received the disease from the cow. The experiment suc- 
ceeded perfectly, the child having received and passed through the disor- 
der in the most satisfactory manner. On the 1st of July following this 
child was inoculated with variolous matter, and resisted the contagion 
entirely, as Dr. Jenner had expected. It was not, however, until two 
years later, in 1798, — after additional experiments, that the results of 
his researches were published to the world. From this time the belief in 
the utility of vaccination, and its application in practice spread rapidly 
throughout England. In 1799 it was introduced into this country ; in 1800 
it reached France, and in the course of a very few years extended to all 
civilized nations. 

Symptoms; Course. — It is very important for the physician to be 
thoroughly acquainted with the appearances presented by the vaccine 



588 VACCINE DISEASE. 

disease in its various stages, since it is lie who must judge by those ap- 
pearances whether the subject has had the disease in such perfection as 
to derive all the benefit from its protective power which it is possible for 
it to impart. 

The first effect of the puncture by which the virus is introduced into 
the tissues, is to produce a very slight redness at the point where the 
operation is performed. This redness usually disappears within twenty- 
four hours, and there is left merely a little mark or scab at the point of 
insertion. On the third day after the operation we first begin to perceive 
the specific effects of the virus, in the shape of a small hardened point at 
the seat of the wound, surrounded by a faint erythematous redness. Over 
this hardened point, which grows gradually larger, the cuticle is elevated 
on the fifth day into a vesicle, by a thin, transparent, and pearl-colored 
serous exudation. This vesicle soon becomes umbilicated, so that by the 
following day, the sixth, the depression in the centre, constituting the 
umbilicated character, is generally perfectly manifest, and at the same 
time the vesicle is surrounded by a very narrow ring of inflammation. 
The vesicle continues to increase in size, until on the eighth or ninth day it 
has reached its highest degree of development. At this stage the vesicle 
or pock is large, usually about one-third of an inch in diameter, and it 
projects very considerably above the general surface. Its shape is circular 
as a general rule, though not unfrequently it is oval, this depending ap- 
parently upon the mode in which the puncture has been made. The color 
of the pock is dull white or pearly, or sometimes it has a yellowish tint. 
The quantity of fluid contained in the cavity of the vesicle differs, of 
course, according to its size. The structure of the pock is found, upon 
careful examination at this time, to be cellular, the number of cells 
amounting, commonly, to eight or ten ; very often there is a small, dark- 
colored scab on the very centre of the vesicle even at this period, though 
in other instances this is absent, the surface of the vesicle being formed, 
exclusively, of the thin and transparent cuticle. The scab just alluded to 
has seemed to me to consist of the little incrustation, formed at the point 
where I had introduced the virus, by the drying up of the minute quan- 
tity of blood escaping after the puncture, and of the dissolved virus 
which had not been absorbed. I have often noticed that when the small 
scab just alluded to has been rubbed off the arm on the second day, the 
vesicle has presented no scab as early as the eighth day. On the eighth 
day the little ring of redness at the base of the pock, which has hitherto 
been very small and narrow, begins to enlarge so as to form the areola. 
This increases during the ninth and tenth days, forming a brilliant scarlet 
or dark red inflammatory circle of about two inches in diameter, and con- 
stituting one of the most strongly marked features of the vaccine disease. 



SYMPTOMS. 589 

The color of the ring is most intense at the edge of the vesicle, and then 
fades gradually to its outermost boundary. On the ninth and tenth 
days, in connexion with the areola, the skin and cellular tissue on which 
the vesicle is seated, and for a short distance beyond the margin of the 
latter, become hardened and tumefied, forming a solid knot or lump in 
the derm like the base of a furunculus. The inflammation which causes 
the areola is often so intense as to occasion the production of vesicles, 
which are almost always discoverable with the aid of a lens, and are some- 
times distinctly visible to the naked eye. On the tenth day, the dis- 
ease is usually at its height, and it is then of course that all its peculiar 
characteristics are most strongly marked. At this time the child, when 
of an age to describe its sensations, will often complain of heat, itching, 
and pain in the inflamed spot; the arm is heavy and not willingly moved, 
or it is moved with care and caution; there is, in a good many instances, 
some irritation and swelling of the axillary glands, and very frequently a de- 
cided febrile reaction may be noticed. In other cases, on the contrary, 
none of these symptoms will be present. The child is gay and cheerful, 
its movements free, quick, and unembarrassed, and it seems in all respects 
to be in its ordinary condition of health. 

From the tenth day the disease begins to subside. The areola fades so 
as to have nearly disappeared by the fourteenth day ; the fluid contained 
in the vesicle is gradually converted into pus, and the cellular structure 
of the pock is broken down so as to form, by the thirteenth day, but a 
single cavity in which the pus is contained ; the process of desiccation is 
going on rapidly during this time, so that about the fourteenth day, the 
vesicle has disappeared, and in its place there is a firm, hard scab, of the 
shape and size of the vesicle. This scab continues to harden for some 
days longer, and at the same time contracts somewhat in size, and grows 
darker in color, until at last it is of a very dark brown or mahogany tint. 
It separates gradually from the tissues beneath, the separation begin- 
ning at the circumference, and falls off usually about the eighteenth or 
twenty-first day, leaving beneath a small ulcer which soon heals, or else 
a cicatrix of the shape and size of the pock. The cicatrix is at first of 
a deep red or purple color, but fades gradually, until it becomes much 
whiter than the surrounding skin. The scar left by the vaccine disease is 
very characteristic, and is often, though not by any means invariably, in- 
delible. To be at all depended on as a mark of the disease, the scar 
should be small, circular, of a smooth and somewhat shining appearance, 
and it should exhibit radiations and little depressions or pits. The 
depressions are supposed to have been caused by the cells constituting the 
pock in its early period. 

There is rarely more than a very slight constitutional disturbance 



590 VACCINE DISEASE. 

attendant upon the course of this disease. About the eighth day, a de- 
cided febrile reaction, attended with some unusual warmth of the surface, 
restlessness at night, and fretfulness of the temper, is often observed. In 
a few instances I have noticed distinct disturbance of the health about 
the third and fourth days ; amounting only, however, to unusual irrita- 
bility and discomfort through the day, and to wakefulness or disturbed 
sleep at night. 

Irregularities and Anomalies. — I have now described the regular 
course of a vaccination, — that which it pursues in a large majority of the 
cases. Certain variations from the above standard or typical course are 
frequently, however, met with, and require some notice. These variations 
may consist merely in the degree of severity of the local and general 
symptoms, or in the appearances presented by the pock, without affecting 
at all the validity of the disease; or they may concern the duration of 
the phenomena ; or, lastly, they may be such as to call in question the 
reality of the disease, leaving us in some doubt as to whether it has pro- 
tected the constitution against variolous attacks or not. 

The severity of the local inflammation occasioned by the vaccination, 
and that of the general symptoms also, varies often to a considerable 
extent. In some instances, and especially when the virus employed has 
been procured recently from the cow, the specific inflammation proves 
very severe. I have seen the arm intensely red, and very considerably 
swelled, from the shoulder to an inch below the elbow, while at the same 
time the axillary glands were tumefied and tender, and the child very 
feverish and uncomfortable. This happened in three children, in all of 
whom I had employed the same virus ; which, as I afterwards learned 
from the person from whom I obtained it, had been taken quite recently 
from the cow. It produced the same violent inflammation, moreover, 
in several other subjects in whom it was employed. 

If the vesicle happens to be broken by accident soon after its forma- 
tion, its appearances during the subsequent progress of the disorder will 
often be very different from those exhibited in subjects in whom no such 
accident occurs. The vesicle loses a portion of its contents ; it becomes 
conoidal and irregular in shape, instead of being circular and umbilicated; 
it does not exhibit the pearly white and diaphanous color which belongs 
to it, but is yellowish and opaque ; the areola is often premature and 
irregular in shape, and the scab is frequently small, uneven on the edges, 
and falls off at an unusually early period. 

Occasionally there is observed in the course of cow-pox a papular erup- 
tion over the body of the child. This occurs usually between the ninth 
and twelfth day. 

It is quite common for the disease to be retarded in its progress. The 



IRREGULARITIES — DIAGNOSIS. 591 

delay generally takes place in the appearance of the vesicle, this not 
showing itself until the sixth or eighth day, or, in some rare instances, 
not until the sixteenth, or even the twentieth, or forty-sixth day. The 
longest retardation that I have met with has been seven days. In this 
kind of retardation, the disease usually runs through its regular and 
natural phases after the vesicle has once made its appearance. In an- 
other kind of retardation the delay occurs in the vesicular and pustular 
stages of the affection, the papule appearing at the ordinary time, but the 
disease not reaching its height or maturity until the eleventh or twelfth 
day. 

The forms of variation from the ordinary course of cow-pox just de- 
scribed, do not seem to be connected with any diminution in the protective 
power of the disease. 

It sometimes happens that the operation of vaccination gives rise to a 
disease, totally unlike the true vaccine disease, one which does not protect 
against small-pox, and which has therefore been called spurious vaccina- 
tion. 

It was formerly the custom to describe quite a variety of appearances 
as indicating with greater or less probability a spurious disease. Of late 
years, however, it is generally admitted that the spurious pock is of much 
less frequent occurrence than was at one time supposed, and that when it 
does occur, its characters are so marked as to make it easy of recognition. 
In fact, it happens in a very large majority of cases, that the vaccination 
either fails entirely, the puncture being productive of no other results 
than those which would naturally flow from a slight wound of the skin, 
or else that it is followed by a true and easily recognised vaccine pock. 

When, however, the operation is followed immediately or within a day 
or two days by inflammation, and the appearance of a pustule, without 
the previous production of a vesicle ; when this pustule is irregular in 
shape, yellow in color, acuminated, easily broken, and terminating in a 
soft, yellowish, ragged-looking crust, which falls off upon the fifth, sixth, 
or seventh day, there is assuredly reason enough to call the vaccination 
spurious, and it becomes the imperative duty of the practitioner to regard 
it as such until subsequent and repeated trials with other and fresh virus, 
have proved the child to be protected. 

Diagnosis. — There can be no difficulty whatever in distinguishing the 
vaccine disease when it occurs in its regular form. The successive phases 
through which the eruption passes, and the particular appearances which 
it presents in each stage, are so unlike all other diseases, except, indeed, 
small-pox, as to render it very easy of recognition. 

Sometimes, however, there is a little difficulty in determining whether 
the eruption is spurious or regular. But this rarely happens except 






592 VACCINE DISEASE. 

under circumstances in which we should expect some modification in the 
phenomena of the disease, to wit, when its course is interfered with by 
the effects of a previous vaccination, or of an attack of variola. The 
irregularities arising from these causes are such as might be anticipated, 
and will be described in the article on revaccination. Whenever, how- 
ever, the disease fails, in any important respect, to exhibit the perfect 
attributes of a well-marked pock, both as regards its times of develop- 
ment and its changes, and its particular appearances at each stage, in a 
child not previously vaccinated, nor having had small-pox, the only wise 
and prudent plan to follow is to repeat the operation a few weeks after the 
doubtful one, so as to test thereby the protective power of the first. 

Protective Power. — Though vaccination has not proved so sovereign 
a means of protection against variola as it was at one time hoped it would, 
it has always seemed to me that those who deny, or even question in 
a serious way, its incalculable benefit to the human race, as some have 
recently been found to do, deserve to be classed amongst the blindest and 
most unphilosophical, or worse still, the most ungrateful of mankind, for 
thus refusing to a kind Providence that meed of earnest gratitude which 
they undoubtedly owe. For, though a single vaccination may fail to 
afford perfect immunity against variola, the attacks of the disease which 
follow even a slight vaccination, are, in a large majority of cases, neither 
dangerous to life, nor are they followed by deformity of any kind. More- 
over, a primary vaccination almost always affords perfect protection up to 
the age of puberty, thus preserving our race from a loathsome and dan- 
gerous malady, precisely in that period of life during which nearly all 
diseases prove most inimical to life. A single fact from my own expe- 
rience will serve to show how great is the debt we owe to vaccination, 
and ought to silence every cavil against this greatest of all prophylactic 
means granted to man. This fact is, that during the last eleven years, in 
which time I have been constantly and busily occupied in practising 
amongst children, I have met with but two cases of natural small-pox 
under fifteen years of age, and these occurred, one in a child two and a 
half years, and the other in one three weeks old, neither of whom had 
ever been vaccinated j nor have I, during that time, seen more than two 
or three cases of modified small-pox or varioloid, under the age specified, 
though three well-marked epidemics of variola have prevailed during 
these eleven years. When we consider, too, that recent observation has 
shown that the practice of revaccination somewhere about the age of 
puberty, or soon after, has almost always been sufficient to restore to the 
constitution that exemption from small-pox which may have been more 
or less diminished after a primary vaccination performed in infancy, our 



SUSCEPTIBILITY. 593 

admiration and appreciation of Jenner's discovery cannot but be raised 
still higher. 

Susceptibility to the Disease. — The susceptibility to the vaccine dis- 
ease varies greatly in different persons and different families, and is modi- 
fied to a greater or less extent by the existence of other diseases in the 
individual at the moment of the operation. In some it is said never to be 
received, no matter how frequently or how carefully the virus may be 
inserted. In others it is received with difficulty, requiring several repe- 
titions of the operation before it can be made to take; whilst in yet 
another class of subjects, the smallest amount of virus, when inserted in 
a careless and imperfect manner even, will produce the disease with the 
greatest certainty. It may be safely asserted, however, that a large 
majority of children take the disease after a single operation, if this be 
performed with ordinary care and nicety. No explanation of the different 
susceptibilities of individuals to the disease can be given. The same 
difference is known to exist in regard to other contagious and even 
epidemic diseases, as measles, scarlatina, pertussis, variola itself, typhoid 
fever, malarious affections, and cholera. 

The susceptibility varies also in the same person at different times, 
without its being possible to ascribe this fact to any evident cause, since 
the child may appear on both occasions to be in the same condition as to 
health and other circumstances likely to influence its susceptibility to the 
contagion. Thus, I knew a child a few months old to be vaccinated four 
times, twice by my father and twice by myself, each operation following 
rapidly the preceding one, without success, though the virus was known 
to be good from its having succeeded in other subjects, and though it was 
changed each time. This child appeared to be in perfect health. There 
was no eruption of any kind upon its surface, nor any other condition 
that could explain its insusceptibility. After the fourth operation, the 
attempt was suspended for about four months, then renewed by my father, 
and with instant and entire success. 

Certain eruptions existing previously upon the surface, have seemed to 
me to prevent the reception 'of a vaccination. The eczematous and im- 
petiginous diseases of infancy and childhood have certainly had this 
effect in my experience, though M. Taupin (Diet, de Medecine, t. xxx. 
p. 406) is of the contrary opinion ; he having found that the disease has 
been merely retarded when the operation was performed during the pro- 
dromic stage of the eruptive fevers, whilst its course was suspended even 
entirely when any of these affections occurred in a child already vaccinated, 
to be resumed again after the cure of the eruptive fever. 

There is another circumstance concerning the supposed effects of other 
diseases on the vaccine affection, to which it will be well to draw attention. 

38 



594 VACCINE DISEASE. 

I am sure there are few practitioners, having any considerable amount of 
business, but must have been annoyed, and injured perhaps in their repu- 
tations, by the notion so prevalent in the community, that vaccination may 
impart to children other diseases. This prejudice exists particularly in 
regard to the chronic cutaneous eruptions of infancy and childhood, so 
that I have frequently had parents to insist to me that the impetiginous 
or eczematous disease under which their child might be laboring, has 
been caused by the vaccination, performed perhaps recently, or even 
months before. M. Taupin, quoted by MM. Guersant and Blache (Diet, 
de Med. t. xxx. p. 414) vaccinated a large number of children at the 
Children's Hospital in Paris, with virus taken from subjects affected with 
itch, scarlatina, measles, varicella, varioloid and variola, rachitis, scro- 
fula, tubercles, chronic eruptions of the scalp, dartres, &c, without com- 
municating to the patient any of these affections, either those of acknow- 
ledged contagious or non-contagious nature. I mention the result of 
these experiments in order to show how little foundation there can be for 
the popular notion above alluded to, and to give to the practitioner an 
arm with which to defend himself against the unjust accusations of those 
who may assert his vaccination to have been the cause of any disorder 
that may have followed upon it. Not that I would myself ever employ 
virus taken from a child suffering from disease of any kind whatsoever, 
since this is, to say the least, unnecessary, and ought to be avoided. In- 
deed I have never employed a vaccine crust taken from a child who was 
not apparently in perfect health. The smallest amount of cutaneous 
eruption upon a child has always been sufficient reason with me to reject 
the virus afforded by such a patient, and as this must be the safest plan 
to adopt, it is of course the proper one. 

Operation. — Different methods of inserting the vaccine virus have been 
employed by different practitioners. The two methods most frequently 
resorted to are those by incision and puncture. The former consists 
in making a superficial incision of several lines in length into the skin, 
in such a way as to cause a very slight effusion of blood. Into this is 
introduced a small quantity of a dried vaccine scab reduced to a fine 
powder, or a piece of fine thread wet with the vaccine fluid or with 
water holding in suspension a portion of dried virus. Over the wound is 
then placed a piece of isinglass plaster, which is secured by a bandage. 
This is to be removed after two or three days, and the disease allowed to 
pursue its regular course. The operation by puncture is performed by 
introducing horizontally beneath the skin a needle or lancet charged with 
the virus, and then withdrawing it in such a way as to leave the virus in the 
wound. Of these two modes the latter is the one now almost universally 
adopted, the former having been found to occasion, not unfrequently, a 



OPERATION. 595 

spurious disease, and to be of very difficult application in the cases of 
children. For my own part I have used for some years past a method 
that I have found much the most convenient in children, and which rarely 
fails when it is carefully performed. I take a common thumb lancet, 
which should not be too sharp. Holding the arm of the child with my 
left hand, and stretching the skin between the forefinger and thumb, 
whilst the under part of the arm is grasped by the second finger placed 
beneath the first, I lay the lancet flat upon the skin, and using the point, 
remove, by a repeated and very gentle rubbing movement, the cuticle, 
until the surface of the derm is laid bare, so as to allow of a perceptible, 
and merely perceptible oozing of blood, or, in other words, so as to ex- 
pose a living surface. This surface should be about as large as a small 
sized bird shot, and it should not bleed, but merely show that the vascu- 
lar part of the derm has been reached and slightly exposed. On this 
surface the vaccine fluid or dissolved scab is to be placed in quantity suf- 
ficient to cover it, and the nurse should be told to leave the arm bare and 
untouched for twenty minutes, or until the applied fluid has dried into a 
little scab, when no further precautions are necessary. This mode of 
operating may at first seem tedious and painful. I can only say that 
when performed gently and gradually, it causes so little pain that I have 
often practised it upon sleeping children without waking them. 

It was at one time thought necessary to make several punctures in 
order to insure a successful inoculation, some making two, and others as 
many as five. In this city one only is generally made, and is found to 
answer every purpose. When, however, there has been any difficulty in 
making the child take the disease, I have on several occasions succeeded 
better by making two insertions, one being situated about half an inch or 
an inch below the other ; nor have I found that the local inflammation 
or general symptoms have ever been severe enough to cause me to regret 
this mode of operating. 

The place usually selected for the operation is, as every one knows, on 
the arm, close to the insertion of the deltoid muscle. This is the best 
place as a general rule, and particularly in girls, whose parents often ob- 
ject to having the insertion made below this, lest the scar should be visi- 
ble in after years, when the arm is uncovered. In boys I often select the 
radial edge of the forearm some two inches below the elbow, since in 
this place the pock is least apt to be injured in the act of dressing the 
child, or of lifting it about. 

REVACCINATION. 

That the prophylactic influence of a primary vaccination is diminished, 
and in some instances entirely lost, by the progress of time, has been 



596 REVACCINATION. 






most positively and clearly shown by the observations of latter years. 
To prove the truth of this it is merely necessary to state, that almost all 
recent writers on the vaccine disease recommend a recourse to revaccina- 
tion some years after the first operation. With the view of bringing this 
matter fairly before the reader, I will quote the opinions expressed by 
some of the leading authorities of the day. 

Dr. Gregory (Loc. cit., p. 346) says : " The practice may be recom- 
mended for its safety, even if it be much less serviceable than the Ger- 
mans contend for. We have sufficient facts before us to state that it 
need never be recommended prior to the tenth year of life, and that the 
age best fitted for it is from the period of puberty to that of confirmed 
manhood." Guersant and Blache (Diet, de Med., deux. ed. t. iii. p. 435) 
have revoked their first opinion that revaccination was unnecessary, and 
state that they now believe firmly " that its protective power becomes 
enfeebled and does not preserve the individual from contracting variola 
in a more or less favorably modified form; and that in consequence 
revaccination ought to be zealously recommended and propagated." The 
Academy of Medicine of Paris, consulted by government upon this ques- 
tion some years since, determined that revaccination was unnecessary. 
In February, 1845, however, the same learned body, after reconsideration 
of the matter, arrived at different conclusions. Two of these I shall 
quote. " Revaccination is the only method of proof which science pos- 
sesses of distinguishing persons who have been definitely protected by 
vaccination from those who are so only in various degrees." 

" The trial by revaccination does not constitute a certain proof that 
those of the vaccinated in whom it succeeds were liable to contract variola, 
but only a tolerably strong presumption that it was particularly amongst 
them that the disease would have been apt to occur. In ordinary periods 
revaccination ought to be performed after the fourteenth year of life ; 
when the disease is epidemic, it is prudent to resort to it earlier." (Guer- 
sant and Blache, Loe. cit. p. 436.) 

MM. Rilliet and Barthez say (t. ii. p. 538) : " The diminution of the 
protective power of vaccination, after a certain number of years, seems to 
be positively proved, but it is proved also that this diminution is almost 
nothing during the period of life which concerns us." Dr. Condie says (Dis. 
of Children, 2d ed. p. 466) : " If, therefore, the facts upon record are per- 
fectly accurate, and there is no reason for suspecting them to be otherwise, 
they afford conclusive evidence of the necessity and importance of revac- 
cination, in all cases in which persons are liable to be exposed to the 
infection of small-pox." It is scarcely necessary to remark that all indi- 
viduals residing in a district in which the disease is prevailing, are ex- 
posed to the infection, and, therefore, according to the above quotation, 






REVACCINATION. 597 

all ought to be revaccinated, which is what I am seeking to establish. 
Dr. G-eorge B. Wood, to whose work on medicine I would refer the 
reader for a very accurate and full account of vaccination and revaccina- 
tion, terminates his remarks on the latter subject with the following 
paragraph. "In concluding the subject, I would again strongly urge the 
propriety of universal revaccination, as the means not only of promoting 
the comfort and possibly of saving the life of the individual, but also of 
preventing the spread of small-pox, and of ultimately eradicating it, if 
not from the globe, at least from extensive communities." 

I might quote, in further proof of the propriety and necessity of revac- 
cination, many other evidences emanating from various sources, but with 
the following short account of my own experience in regard to it, I shall 
bring my remarks to a close. In the year 1845 I revaccinated 63 per- 
sons, of whom 9 had the disease with every appearance of regularity, 
that is to say, the puncture did not become irritated until the third or 
fourth day, the vesicle was perfect on the ninth, with the umbilicated 
centre, hard base, and scarlet areola, and after that period the inflamma- 
tion subsided rapidly. Of these 9, all but one had characteristic cicatrices 
of previous vaccinations on the arm. The ninth was doubtful, but the 
individual insisted that he had been properly vaccinated. Of the remain- 
ing 54 cases, the great majority presented more or less strongly marked 
signs of the disease. In nearly all a -yellowish pustule was formed some 
time during the second day, which was surrounded by an irregular patch 
of redness of small extent, presenting often a dotted or marbled look. 
In some the appearances promised a regular vaccine vesicle for several 
days, but terminated suddenly by the drying up of the vesicle, and the 
formation of an ill-shaped acuminated scab, which soon fell off, leaving a 
slight scar quite different from that of a primary vaccination. 

The only remaining point for consideration is the period of life at which 
revaccination ought to be performed. The prevailing opinion seems to 
be that somewhere about puberty is the most suitable time, unless in the 
cases of children- exposed immediately to the infection of the disease, 
when it may and ought to be resorted to at a much earlier period. 



ARTICLE V. 



VARICELLA. 



Definition ; Synonymes j Forms. — Varicella is a contagious eruptive 
disease of benign nature, characterized by more or less numerous trans- 



598 VARICELLA. 

parent vesicles following rapidly upon small red elevations. The erup- 
tion is usually preceded by slight prodromic symptoms lasting from one 
to two days, and it terminates by the desiccation of the vesicles about the 
fifth or eighth day after their appearance. 

It is known also in English by the names of chicken-pox, swine-pox, 
and crystalli. 

Several different forms of the disease have been described by different 
writers under the titles of the lenticular, conoidal, and globular varieties, 
but inasmuch as these varieties are of no real importance in practice, I 
shall merely advert to them casually in my account of the eruption. 

Causes. — Varicella is propagated in two ways ; by contagion, and by 
epidemic influence. That it is contagious there can be no doubt, since 
nearly all observers agree upon this point. In my own experience I have 
seldom known any child, who had not had the disorder previously, to 
escape it when once it has entered a household. It rarely attacks any 
but children. Its epidemic nature is shown by the fact that in some 
seasons it is scarcely seen, whilst in others it prevails extensively over 
large districts of country, and attacks many children in the great towns 
and cities of those districts. Varicella occurs only once in the same indi- 
vidual. 

Considerable discussion has taken place at various times as to the real 
nature of varicella, some asserting that the disorder is merely one of the 
varieties of modified small-pox, while others maintain as strongly that it 
is an independent and specific disease. The weight of authority, however, 
seems to be clearly in favor of the last-mentioned opinion, and I have no 
hesitation in avowing this to be the conclusion to which my own reading 
and experience have brought me. When we consider, indeed, that vari- 
cella is, unlike either variola or varioloid, incommunicable by inocula- 
tion, that it attacks indifferently the vaccinated and unvaccinated, that its 
course is entirely unaffected by previous vaccination, and that the vaccine 
disease is readily taken, and passes through its regular phases after vari- 
cella, I do not see how we can refuse to believe that the latter is some- 
thing entirely independent of small-pox, and therefore a distinct and 
peculiar malady. 

Symptoms j Course; Duration. — The eruption is usually but not 
always preceded by prodromic symptoms. These seldom last more than 
one, or at most two days, and consist at the very beginning of slight 
chilliness, or of a chill even, which is followed by a more or less marked 
febrile reaction. In some instances there is vomiting, but this is rare, 
and when it does occur, slight. When fever exists it is marked by head- 
ache, accelerated pulse, pain in the back and limbs, languor, indisposition 
to play, some unusual irritability of temper, diminution or loss of appe- 



SYMPTOMS. 599 

tite, unusual thirst, and by slight warmth of the surface. These symp- 
toms may be present, and yet in so mild a shape that the child shows no 
disposition to abandon its ordinary habits of activity and play, while in 
other cases again, there are literally no initiatory symptoms whatever, 
and the appearance of the eruption is the first declaration of the presence 
of the malady. Even when constitutional symptoms are present, they 
usually disappear by the third day. 

The eruption appears in the form of small papular spots, of a deep red 
color, and irregularly circular shape, which generally show themselves 
first on the front and back of the trunk, and then extend very soon to the 
face, and a little later, to the extremities. I have known a child to go to 
bed at night with slight headache and fever, and present a well-marked 
though not yet abundant varicellous rash upon the upper part of the trunk, 
and on the face, on the following morning. These papules exhibit, in the 
course of a very few hours, small vesicles in their centres; indeed, 
according to some observers, the eruption is vesicular from the very 
beginning. On the second day the papules are in great measure converted 
into vesicles, which may be either small and acuminated, constituting the 
lenticular form of the disease, or they may be larger and of a more glo- 
bular shape, constituting the conoidal and globular or globose forms of 
Willan and Bateman. I deem it unnecessary, as above stated, to describe 
different varieties of varicella, since this is useless for any practical pur- 
poses, and because I constantly see upon the same subject vesicles of 
very different shape and size. When fully completed, the vesicles are 
often of very considerable size, — two or three lines in diameter ; they 
contain a transparent fluid, which is either entirely colorless or of a 
faint orange tint, and some of them are surrounded by a small ring of 
inflammation. On the third day, the eruption continues in nearly the 
same state as on the second, except that the fluid contained within the 
vesicles assumes a yellowish appearance, owing to its passage from the 
serous into the purulent condition. On the fourth day the process of 
desiccation begins and goes on rapidly, the vesicles that have not been 
broken by accident, or torn by the fingers of the child in its efforts to 
appease the itching which they give rise to, assuming a shrivelled and 
shrunken appearance at their margins. As this process goes on the 
vesicles are gradually converted into light brownish scabs, so that by 
the sixth day they are nearly all dried up. The scabs are usually thin ; 
they dry from the circumference to the centre, and between the eighth 
and ninth day fall off, leaving behind faint red spots, not depressed below 
the general surface, and which soon disappear. 

The eruption is generally accompanied, as was stated above, by a sensa- 
tion of heat and itching in the vesicles, which causes the child to rub and 



600 VARICELLA. 

scratch them in such a way as often to break those which he can reach, 
and thus prevent them from passing through the regular periods of matu- 
ration and desiccation. 

Diagnosis. — There is but one disease with which varicella could be 
confounded and that is variola in some of its shapes. With regular 
small-pox such a mistake could scarcely happen even to the most inexpe- 
rienced. With varioloid, on the contrary, there might be some difficulty, 
and yet, if it is borne in mind that in varioloid the initiatory fever is 
much more severe, lasting three or four days instead of twelve or thirty- 
six hours, that the eruption appears first on the face and extends very 
slowly to the trunk and extremities, and that the conversion from the 
papular into the vesicular condition is much more gradual than in 
chicken-pox, I think no serious difficulty can ever occur in making the 
distinction between the two affections. 

Prognosis. — The prognosis is always favorable. The only real trouble 
that I have ever known to occur has been from catarrh or pneumonia con- 
tracted by imprudent exposure during the convalescence. 

Treatment. — In a large majority of the cases, varicella requires no 
treatment beyond attention to diet during the first two or three days, 
and the avoidance of cold during the convalescence. When the con- 
stitutional symptoms are marked, the fever and headache being con- 
siderable, a dose of some mild cathartic, a little sweet spirits of nitre in 
cold lemonade or orangeade, rest in bed, and one or two footbaths, will be 
all that is necessary to reduce these symptoms and make the patient 
comfortable. 



CLASS V. 

DISEASES OF THE SKIN. 

INTRODUCTORY REMARKS. 

It would be worse than useless in a work like the present, which is 
necessarily restricted within certain limits as to size, to attempt a full 
description of all the diseases of the skin to which children are subject. 
Such a course would compel me to devote to more important matters than 
the affections of the skin, a much smaller proportion of space than they 
require and deserve. I shall therefore select only those cutaneous dis- 
eases occurring in early life, which are most important either from their 
frequency, or because they present in children some particular aspects or 
peculiarities, which make it necessary that they should be studied sepa- 
rately from the same maladies in adults. Moreover, I shall treat of each 
one as it comes before us with greater or less copiousness of detail, ac- 
cording to its respective consequence to the medical practitioner, eschew- 
ing carefully any useless detail in regard to the more unimportant kinds, 
but endeavoring anxiously to describe with accuracy the history, diagnosis, 
and treatment, of such as demand a greater degree of consideration. 



CHAPTER I. 

RASHES. 
ARTICLE I. 

ERYTHEMA. 

Definition; Frequency; Forms. — Erythema is a non-contagious 
exantheme, characterized by a slight and superficial redness of the skin, 
appearing in patches of irregular form and uncertain extent. It may or 
may not be preceded or attended with signs of constitutional disorder. 
It is quite & frequent affection in some of its forms. 

I shall describe three forms of the disease, restricting myself, as I have 



602 - ERYTHEMA. 

already said that I should, to those which seem particularly impor- 
tant in infancy and childhood. These forms are Erythema Fugax, 
Erythema Intertrigo, and Erythema Nodosum. 

Erythema Fugax. — This form of erythema occurs chiefly in the 
course of various acute internal inflammations, and especially those which 
occur during dentition. It may occur during high febrile reaction 
brought on by any cause, especially in children having an active cutane- 
ous circulation. I have observed it several times in the local inflamma- 
tions of children accompanied with great disturbance of the circulation, 
and particularly in a case of severe catarrh occurring during dentition, 
and in attacks of severe simple angina. In these cases it appeared in the 
form of a bright red rash, resembling very much a mild scarlatinous 
eruption. It was seated upon the upper part of the front of the thorax, 
and upon the outer surfaces of the arms. The red flush disappeared 
readily under pressure, and flashed back the moment the pressure was 
removed. There was no swelling attending it whatever, and the color 
was never so bright as that of a severe scarlatina, nor so deep as that of 
erysipelas or roseola. It lasted only a few hours or half a day, and then 
disappeared without desquamation. 

The only point of interest in regard to this form of erythema, as it has 
come under my notice, has been the diagnosis between it and scarlet 
fever. This is to be made out only by recollecting that it has made its 
appearance in the course of another disease, while the child is already 
suffering under some kind of sickness, which is not generally the case 
with scarlatina; by the less scarlet tint of the eruption, its more superfi- 
cial character, and more limited extent; and lastly, by its short duration. 

Erythema Intertrigo. — This form of erythema was for a long time, 
and is still by some, known by the single name of intertrigo. It occurs 
on the portions of the body exposed to friction by the contact of opposite 
surfaces, and to irritation from the passage over, or retention upon them, 
of the urinary secretion or the faecal discharges. The most common 
seats of it are, therefore, in the folds of the skin about the neck, in the 
axillae, the groins, about the anus, in the cleft of the nates, and on the 
inside of the thighs. 

As it appears in the creases of the skin about the neck, or in the 
axillae, it may be a mere blush of redness lasting a few days, and then 
disappearing ; or, after presenting this appearance for a short time, the 
inflammation may become much more intense, and occasion an excoriated 
condition of the surfaces attended with the discharge of a serous or a 
sero-purulent fluid ; or, lastly, the inflammation may run into veritable 
ulceration, giving rise to extensive and very painful ulcers occupying the 
depth of the crease, presenting abrupt and jagged edges, and discharging 



SYMPTOMS. 603 

very considerable quantities of pus. In one child, two months of age, of 
delicate constitution, and imperfectly supplied with food, I saw the last 
described form of the disease occupying at the same time the groins, the 
axillae, and the folds of the neck. The attack lasted two weeks, and very 
nearly proved fatal from the violent suffering it caused. In another 
child, not quite a year old, who was teething, it presented these characters 
in the neck and axillae, while in the groins it was much less severe, the 
latter parts being merely excoriated. 

Infants attacked with severe diarrhoea, with dysentery, or entero-colitis, 
and especially with that form of entero-colitis which so generally accom- 
panies thrush, are very apt to have an erythema of the nates, genital 
parts, and the internal surfaces of the thighs. So common, indeed, is 
this occurrence, that M. Valleix regards erythema of these parts as an 
almost constant accompaniment and even precursor of thrush. For my 
own part I have very often met with it in cases of diarrhoea in infants, 
even in those of very moderate severity, but I have never seen it precede 
the appearance of the intestinal disorder. 

This form of erythema begins as a simple redness of the skin about the 
anus, between the buttocks, about the genital parts, and over the inside 
of the upper parts of the thighs. In a mild case of diarrhoea, and in a 
child properly cleansed after each evacuation by stool or urine, it will go 
no further than this ; but in a severe attack of inflammatory diarrhoea, 
attended with frequent acid stools, and in a case in which proper cleanli- 
ness is not attended to, the long-continued contact of the discharges and 
soiled napkins will often cause the erythema to assume very distress- 
ing features. The redness extends in such instances along the leg to the 
feet ; small papules, more or less numerous, make their appearance upon 
the inflamed skin ; these are converted into pustules and then into ulce- 
rations, and if the case goes on unchecked, the ulcerations become larger, 
run together, and present raw, deep red, and bleeding surfaces, sometimes 
of considerable size. Very often the ulcerations present a grayish plastic 
exudation upon their surfaces. After cicatrization there remain at the 
points where the ulcerations had existed reddish and copper-colored spots, 
which do not disappear for a considerable length of time. This form of 
erythema rarely ceases entirely until the diarrhoea which has occasioned 
it has itself been cured. 

Erythema Nodosum generally occurs in feeble and delicate children. 
I have never met with it under five years of age. It may develope itself 
upon different parts of the body, but occurs in by far the greater part of 
the cases on the forepart of the legs, or over the anterior edge of the tibia. 
I have only twice seen it elsewhere, and then it was situated upon the 
outer surfaces of the arms and forearms. It is preceded usually for 



G04 ERYTHEMA. 

several days by general indisposition, by lassitude, thirst, loss of appetite, 
and some feverishness. It appears in the form of red spots of an oval 
shape, somewhat elevated in the centre, and which increase gradually in 
size. After a short time these patches become decidedly elevated above 
the surrounding surface, and in passing the hand over them they give the 
sensation of nodosities. They increase gradually in size so as to measure 
from a few lines to an inch or an inch and a half long, by half an inch or 
an inch broad, when they present the appearance of reddish tumors, 
somewhat painful to the touch, and having an obscure feeling of fluctua- 
tion, as though about to suppurate. This, however, they never do, but 
after a short time they diminish in size, their Ted color changes into a 
bluish or livid tint, they soften, and finally they disappear entirely in 
about twelve or fifteen days. I have met with five well-marked cases of 
this disease. Three occurred in girls between six and twelve years of 
age, and two in boys of the same age. They all appeared to depend on 
derangement of the digestive function, attended with a somewhat im- 
poverished state of the blood, and general debility. 

Diagnosis. — The only disorders with which erythema could be con- 
founded are erysipelas, roseola, or scarlatina, and this could happen only 
in regard to the erythema fugax. From erysipelas it may be distin- 
guished by the superficial character of the eruption, the absence of swell- 
ing and of smarting and burning pain, and by the slighter severity and 
much shorter duration of the symptoms in erythema. Another im- 
portant feature is the peculiar, abrupt, well-defined, and slightly elevated 
margin which marks the edge of the erysipelatous rash, aud which does 
not exist with the same distinctness in erythema. Lastly, the singular 
regularity observed by erysipelas in its gradual extension from place to 
place, is altogether unlike the march of erythema, which shows itself 
suddenly, or in a few hours, over large surfaces, and after lasting some 
hours or a few days, disappears without having followed the erratic course 
of erysipelas. 

In roseola the peculiar deep rose-tint of the rash will serve to distin- 
guish between it and the lighter red tint of erythema. 

The mild character of the general symptoms and the absence of throat 
affection in erythema, will prevent any one who is careful from mistaking 
the disease for scarlatina. 

Erythema intertrigo cannot be mistaken for any other disease, and if 
the course and peculiar local characters of erythema nodosum be borne in 
mind, it also may be easily recognised. The only thing with which the 
latter might be confounded is phlegmonous erysipelas, but if the mild 
character of the general symptoms in erythema nodosum, the distinctly 
circumscribed form of the tumors, and the fact that the disease never 



PROGNOSIS — TREATMENT. 

terminates by suppuration, are recollected, there need be no difficulty in 
making the diagnosis. 

Prognosis. — Erythema is a very mild disorder in a large majority of 
the cases. The only conditions under which it proves serious are when 
the intertrigo attacks children laboring under chronic entero-colitis, or 
those affected with severe thrush connected with gastro-intestinal inflam- 
mation, when it cannot fail to increase the sufferings and danger of the 
patient ; or, when it implicates, as I have seen it do in two instances, 
extensive portions of the cutaneous surface, involving the folds of the 
neck, armpits, groins, and genital organs, and this, too, without any other 
signs of disorder of the digestive apparatus than those showing functional 
derangement. In one of these cases, the extent and depth of the ulcera- 
tions were so great, and the resulting sufferings and constitutional distress 
so severe, as to have very nearly destroyed the life of the infant, who was 
but two months old at the time of the attack. 

Erythema nodosum would almost certainly excite some uneasiness in 
the mind of a practitioner unacquainted with its real nature and probable 
course, and not only so, but it would prove tedious and difficult of cure, 
unless treated in the proper way. When managed correctly, however, it 
almost always gets well without any difficulty. 

Treatment. — Erythema fugax requires no special treatment. The 
disorder which has occasioned it is the point to which our attention must 
be turned, and not the eruption, which is a mere consequence. 

Ordinary mild cases of intertrigo require no other measures than atten- 
tion to strict cleanliness. The irritated parts must be carefully washed 
two or three times a day, and if the nates, genital parts, and thighs 
are concerned, the washing must be repeated after each evacuation of 
urine or stool. After this the parts should be dusted with fine starch, 
or the powder of chalk or lycopodium, or else well anointed with some 
mild ointment, the best of which is in my opinion Goulard's cerate. The 
washing ought to be performed with a fine soft sponge and warm water. 
The sponge is far better than the cloth generally employed, because, with 
the former, the cleansing can be effected by pressure, whilst with the 
latter it is necessary to use a kind of wiping or rubbing process, which 
cannot fail to irritate the inflamed and tender surfaces. 

When the surfaces have become excoriated or ulcerated, attention to 
cleanliness is as important as ever. The application of the drying powders 
generally employed by the public becomes, under these circumstances, 
insufficient, and often rather injurious, except, indeed, in cases in which 
the excoriation is very slight ; here the lycopodium powder, or very fine 
starch or magnesia, will sometimes answer a good purpose. When the 
excoriation is severe and when ulceration is present, I have never obtained 



606 ERYTHEMA. 

any good effects from powdering; on the contrary, it has often proved 
injurious, and is at least troublesome and annoying, from the incrusting 
of the powder about the ulcer. I prefer, therefore, very greatly, when 
ulceration is present, to dress the part with simple cerate, Groulard's 
cerate, Turner's cerate, ointment of oxide of zinc, an ointment consisting 
of one part of citrine ointment to three or four parts of simple cerate, or 
some such preparation. The ointment should be applied on a fine rag 
greased on one side, the rag being doubled and interposed in such a way 
between the opposite surfaces of inflammation, as to be accurately applied 
to the whole extent of the disease, and thus prevent all friction or even 
contact of the opposite sides. These compresses ought to be changed 
three or four times a day, and all the discharges gently but carefully 
washed off by pressure with the sponge between each change of dressing. 

Whilst this topical treatment is being carried out, constant attention 
must be paid to the state of the digestive function. It is scarcely neces- 
sary to apply this remark to cases occurring in the course of thrush or 
entero-colitis, but there is another class of cases that I have met with in 
which, though the intertrigo is severe and obstinate, lasting as much as 
two, three, or four weeks, the signs of gastro-intestinal disorder are so 
slight as to pass unnoticed unless carefully inquired into. Thus they 
may consist merely in the fact that the child has a few more stools per 
day than usual, or that the stools are more liquid than they should be, 
or that they exhibit marks of derangement of the digestive process by the 
appearance in them of imperfectly digested curd of milk, or by their green 
color and sour smell. Whatever be the character of the derangement of 
this function, as shown by the general appearance of the child, its appe- 
tite, degree of thirst, or the appearances presented by the stools, we 
should always endeavor to rectify the disorder, and if the attempt prove 
successful, we shall often see the intertrigo vanish at once, while before 
it had resisted all the means employed for its cure. 

Erythema nodosum occurs generally, as already stated, in feeble chil- 
dren, and is usually accompanied with constipation or unhealthy stools, 
and slight febrile reaction. The proper treatment is a laxative at the 
beginning of the attack, and again in the course of the disorder if neces- 
sary ; rest in bed or on a sofa, which is very important ; and after the 
operation of the laxative, the administration of tonics, and the use of a 
light but strengthening diet. The best tonic as a general rule is quinine. 
If this is not liked, or if there be anything in the case to contraindicate 
its employment, we may substitute the compound tincture of bark, in the 
dose of fifteen or twenty drops, three times a day. If the child is pale 
and anemical, iron is the proper remedy. It should be given in con- 
nexion with the tincture of bark, or with small doses of brandy, when 



ERYSIPELAS. 607 

the appetite is poor, and the strength and spirits of the child much below 
their natural level. 

Topical remedies are not necessary as a general rule. When, however, 
the local symptoms are severe, or there is much heat or pain in the 
tumors, they should be kept covered with compresses moistened with 
some kind of mucilage, or with lead-water and laudanum. 



ARTICLE II. 



ERYSIPELAS. 



Definition; Forms; Frequency. — Erysipelas is a non-contagious 
exantheme, characterized by a deep red rash, attended with heat and 
swelling of the skin, sometimes with inflammation of the subjacent cellu- 
lar tissue, and terminating generally in resolution, but sometimes in sup- 
ration or gangrene. The disease is very variable as to its extent, and has 
the peculiarity of spreading from place to place, the part first attacked 
recovering, whilst the neighboring surface is becoming affected. 

The disease, as it occurs in children over six months of age, presents 
the same characters as in adults, and requires therefore no particular 
attention in this work. In younger children, on the contrary, and espe- 
cially in the new-born infant, it is different in several particulars from 
that of older children or adults, and this I shall attempt to describe. 
The form which occurs in new-born infants has been technically named 
erysipelas neonatorum. 

Erysipelas is a rare disease in private practice, particularly amongst 
families in easy circumstances. In lying-in and foundling hospitals, on 
the contrary, it is of frequent occurrence, and it is not uncommon in 
hospitals for children and in the children of the poor. I have myself 
met with but three cases of erysipelas in children under six months of 
age, whilst I have met six in older children. 

Causes. — The erysipelas of young children almost always starts from 
some previously existing cutaneous inflammation, the most frequent seats 
of which are the umbilicus during the process of separation of the cord, 
the irritated folds of the skin existing in erythema intertrigo, the inflam- 
mation accompanying the vaccine disease, and that which exists in the 
impetiginous eruptions of the scalp, ears, and face. In a large majority 
of the cases observed in new-born children, the disease begins upon the 
abdomen, and generally at the umbilicus. In those which occur in chil- 



608 ERYSIPELAS. 

dren at the breast, it may show itself at any of the points above men- 
tioned. 

But, though erysipelas commonly starts from, and may at first view 
seem to be produced by these different local irritations, it is impossible 
to suppose that they can be anything more than the exciting agencies or 
causes, which bring into action a disease of which the seeds are already 
existing in the economy. We must, therefore, in order to understand 
the real mode of causation of erysipelas, seek for the conditions that give 
rise to this predisposition to the malady, without which the above-men- 
tioned exciting causes rest without effect. These conditions are either a 
general epidemic constitution of the air, affecting certain districts of 
country, and acting more or less upon all classes of the community, but 
with especial force upon the destitute and miserable; or else a local 
epidemic constitution, such as that often occasioned by the unfavorable 
hygienic conditions of hospitals, and particularly of lying-in and found- 
ling hospitals, or that not unfrequently determined by the same causes 
in the crowded and miserable habitations of the poorer classes of the in- 
habitants of large towns and cities. 

Symptoms. — Infantile erysipelas is not generally preceded by any 
constitutional symptoms. The appearance of the eruption is usually the 
first sign of the disease. As soon, however, as the eruption appears, or 
very soon after, the child is attacked with fever, marked by frequent 
pulse, by heat and dryness of the skin, by restlessness and insomnia, and 
by thirst. In the form of the disease which occurs in very young infants, 
and in hospitals or amongst the lower classes of the population, the erup- 
tion almost always begins upon the abdomen, and very generally at the 
umbilicus, whence it extends to the rest of the trunk, to the genital parts, 
and sometimes to the inferior extremities. Even under the circumstances 
just mentioned, however, the eruption sometimes begins upon the face or 
upon the limbs. In children over two weeks of age, and in those observed 
in private practice, the disease may begin upon any part of the surface. 
It very often begins in the neighborhood of a vaccine pock, in a patch of 
erythema intertrigo, whether this be seated on the neck or about the 
pelvis, or it may appear first upon the face, or upon one of the extremi- 
ties, without any apparent exciting cause, and extend thence with greater 
or less rapidity to other parts of the body. 

The form of the disease which occurs in very young infants, and which 
is by far more frequent in lying-in and foundling hospitals than under 
any other circumstances, begins almost always, at least when of a severe 
type, on the abdomen. It attacks hearty as well as more delicate chil- 
dren, and is generally very rapid in its progress. The erysipelatous sur- 
face is at first of a bright red and shining appearance, but soon assumes 



SYMPTOMS. 609 

a purplish hue, and as this occurs, becomes exceedingly hard to the touch, 
and somewhat, though not very much swelled. As the case goes on, un- 
less resolution, which is a rare event, should take place, or death occur 
at an early period, the purple color deepens into livid, vesications occur, 
the cellular tissue is destroyed, and in many instances extensive gangrene 
takes place, so that the scrotum has been seen to " become black and slough 
away, leaving the testicles bare, and hanging loose by the cords." (Maun- 
sell and Evanson.') In this form of infantile erysipelas, examination after 
death almost always discloses severe and extensive peritoneal inflamma- 
tion, a condition which cannot fail, of course, to add greatly to the danger 
of the disease. 

But infantile erysipelas does not always exhibit these violent characters, 
though whenever it occurs in infants under a year old it must be regarded 
as a very dangerous affection. When it attacks children over two weeks 
or a month old, it usually starts, as has been stated, from the neighbor- 
hood of a vaccine pock, from the inflamed surfaces of intertrigo or those 
of impetiginous eruptions, or it begins without evident cause, as in adults, 
on the face, or on some part of the extremities. It appears first in 
the shape of a bright red inflammation of the skin. After a short time the 
erysipelatous surface becomes tense, shining, very hot, slightly swelled, 
and painful to the touch. Pressure causes the color to disappear, but 
this rapidly returns upon the pressure being removed. Coincidently with 
the appearance of the cutaneous redness the child is seized with fever, 
restlessness, and severe thirst. From the spot first attacked the disease 
extends rapidly to the neighboring surfaces, from the neck and arms to 
the head and trunk, and from the groins or genital parts, to the rest of 
the trunk and to the inferior extremities. When it begins upon the face, 
it extends to the scalp, and may thence travel over the whole surface, or 
it may remain limited, as it so often does in adults, to the head alone. 
In one case that I saw, in an infant three weeks old, in which it began 
upon the face, it extended gradually over the whole cutaneous surface, and 
yet the child recovered ; in another, two months old, it began upon the 
bridge of the nose, and from thence extended over the whole head, but 
did not reach the trunk or limbs ; in a third case a vaccinated arm was 
attacked with erysipelas on the eighth day of the vaccination. The dis- 
ease extended down to the fingers, and upwards to the shoulder. From 
the shoulder it spread gradually over the whole trunk, and down the 
whole length of both lower extremities. As it was subsiding on the feet, 
it appeared on the arm opposite the one first attacked, and then attacked 
the corresponding side of the head, where it ceased. The child finally 
recovered after an illness of three weeks. 

As the peculiar inflammation spreads to the neighboring surfaces, the 

39 



610 ERYSIPELAS. 

parts first attacked lose their red color and swelling, and undergo a pro- 
cess of desquamation. In some instances, the inflammation has caused 
suppuration of the subcutaneous cellular tissue, so that even when the 
greater part of the surface first attacked has ceased to present the pecu- 
liar characters of the erysipelatous inflammation, there remains behind 
abscesses of greater or less extent. Thus, in one of the cases that came 
under my own notice, when the erysipelas had left the head and thorax, 
and was confined to the pelvis and inferior extremities, there were two 
abscesses on the scalp, and one over the right pectoral muscle, whilst all the 
skin between the abscesses had regained its natural appearance, with the 
exception of the desquamative process, which was going on as usual. In 
another, but rarer set of cases, the inflammation sometimes returns to the 
parts over which it has already passed. 

The swelling which accompanies this disease, is usually of an oedema- 
tous nature — this condition being most marked in the hands and feet, and 
upon the face, whilst upon the trunk, it is much less considerable. 

The general symptoms consist at first, as already stated, of those indi- 
cating a strong febrile reaction. If the case goes on favorably these 
symptoms continue until the disorder terminates. But when the disease 
is severe, and especially when it ends in vesication, in extensive destruc- 
tion of the cellular tissue, or in gangrene, the general symptoms are much 
more violent, marking thereby the gravity of the attack. The face and 
lips become pale, and the tongue and mouth dry. The child is in a state 
of constant agitation at first, and expresses its uneasiness and suffering 
by incessant moaning or crying, but after a time it becomes heavy and 
drowsy from exhaustion. The pulse is very frequent and feeble ; diar- 
rhoea and vomiting make their appearance, and the child dies at last in a 
state of profound debility; or convulsions occur towards the last, and 
terminate the case as they so often do in the diseases of infancy and 
childhood. 

The duration of erysipelas in children is extremely uncertain, and 
depends very much upon its form. In that which occurs in the new-born 
child or within one or two weeks after birth, it sometimes proves fatal 
within seven days according to Canstatt (Handbuch der Med. Klinik, 2d 
ed., vol. ii. p. 264). M. Bouchut (Mai des Enf. Nouv.-Ms, p. 532) 
gives as an approximation to the ordinary duration of infantile erysipelas, 
between four and five weeks, and states that this is also the result arrived 
at by M. Trousseau. In one of the cases alluded to by myself, in which 
the disease extended over the whole cutaneous surface, the duration was 
four, while in another it was three weeks ; in the one in which the eruption 
was limited to the head, the duration was a week. In the six remaining 



DIAGNOSIS — PROGNOSIS. 611 

cases, the disease was limited to the nose and eyelids, or the face and 
scalp, and lasted from three to nine days. 

Diagnosis. — The diagnosis is very easy. The peculiar shade of the 
red color, the presence of decided though moderate tumefaction of the 
affected part, the severity of the general symptoms, and the characteristic 
erratic mode of extension from surface to surface, all assist to render the 
diagnosis very clear to those who have any proper amount of medical 
knowledge. 

Prognosis. — Erysipelas is always a dangerous disease in young chil- 
dren. The precise degree of danger in individual cases will depend 
chiefly on two circumstances : first, the age of the subject; and second, 
the hygienic conditions under which the disease occurs. It is always 
exceedingly dangerous in new-born infants, so much so indeed that M. 
Bouchut declares that they all die {Loc. cit. p. 532). This is in all 
probability almost strictly true of the cases which occur in infants only a 
few days old, particularly when they take place in lying-in hospitals, or 
even in private practice, during the prevalence of an epidemic of puerpe- 
ral fever. The disease is always very dangerous in hospitals, even in in- 
fants over two weeks old. Yet it would appear not to be so grave as 
represented by M. Bouchut, who thinks that very few indeed have been 
cured even at that age ; for, of thirty cases in infants between one day and 
a year old observed by Billard at the Foundling's Hospital of Paris, six- 
teen, or only one more than half, proved fatal. Schwebel reports 54 
deaths in 86 cases (Meissner, Kinderkrankheiten, 3d ed., vol. i. p. 372). 

In private practice, erysipelas, as it occurs in children between two 
weeks and a few years old, is a dangerous malady, but yet is far from 
being so in the same degree as in the new-born infant, and in hospitals. 
I have already stated that I have seen three cases in young infants, one 
three weeks old, in whom the disease lasted four weeks, and travelled 
over the whole cutaneous surface, another ten weeks old, and in whom 
also it travelled over the greater part of the cutaneous surface, and a third 
two months old, in whom it remained limited to the head. All of these 
recovered. Again, I have seen six cases of erysipelas of the face or head 
in children between eight months and twelve years old, and these also 
ended favorably. It must be recollected, however, to account for these 
recoveries, that they all occurred in hearty children, and under the most 
favorable hygienic conditions met with in private practice. To conclude, 
MM. Rilliet and Barthez report nine cases of erysipelas of the face in 
children, all of whom, with three exceptions, were over five years of age. 
Five of the nine cases were idiopathic ; in four the disease complicated 
other affections. All of the spontaneous and one of the complicated cases 



612 ERYSIPELAS. 

recovered. The two others, both of which occurred in subjects laboring 
under measles attended with pneumonia, proved fatal. 

Treatment. — The treatment of erysipelas in new-born infants, espe- 
cially when the subjects of the disease are the inmates of a hospital, and 
when it occurs coincidently with a puerperal fever epidemic, is, as may 
be learned from the almost certain fatality of the disorder, exceedingly 
hopeless. M. Trousseau (Barrier, Traite Prat, des Mai. cle VEnfance, 
t. ii. p. 560) has made trial unsuccessfully of emollients in every form, of 
fomentations, lotions, baths, and of ointments containing sulphate of iron. 
" I have tried," he says, " surrounding the whole body and the limbs, 
with blisters in the form of strips ) the erysipelas has passed over the 
obstacle. I have applied without success blisters upon the surfaces 
already invaded by the inflammation. I have obtained no advantage 
from mercurial ointment or from baths containing corrosive sublimate." 
He even tried the application of the actual cautery in points where the 
disease was beginning, but without effect. So, too, with methodical com- 
pression. 

Underwood says, that " upon the complaint being first noticed in the 
British Lying-in Hospital, various means were made use of without suc- 
cess : the progress of the inflammation has seemed, indeed, to be checked 
for a while by saturnine fomentations and poultices, applied on the very 
first appearance of the inflammation ; but it soon spread, and a gangrene 
presently came on ; or where matter has been formed, the tender infant 
has sunk under the discharge." He adds that he then proposed bark, to 
which, sometimes, a little confectio aromatica was added, and that from 
that period several cases recovered. After this, linen compresses, wrung 
out of camphorated spirit, were applied in the place of the saturnine solu- 
tion, and proved successful in several instances in checking the inflamma- 
tion. " Nevertheless, the greater number of infants attacked with this 
disorder sink under its violence, and many of them in a very few days." 
(Treat, on the Dis. of Children, Am. ed., by Dr. Bell, from the 9th Eng. 
ed., p. 103.) In a note to the above Dr. M. Hall states that fomenta- 
tions of extract of poppies diffused in warm water, and poultices consist- 
ing of the same fluid and crumbs of bread, proved beneficial in many 
instances. Dewees recommends the application of a blister, when the 
erysipelas is so situated as to allow the whole surface of inflammation 
and a portion of the neighboring healthy surface to be covered by the 
plaster. When this cannot be done, he prefers the use of the strong 
mercurial ointment, which must be applied over the whole of the erup- 
tion, and partly upon the healthy skin, and renewed as often as the part 
becomes dry. 

It is very diflicult amidst the variety of advice given by different 



TREATMENT. 613 

writers, and especially when we reflect upon the great mortality of the 
disease under every kind of treatment, to determine which to select. 
For my own part, I should prefer the use of cooling emollient applica- 
tions during the first part of the attack, whilst the skin is of a bright red 
color, hot, and shining. When the circulation becomes languid, and the 
color of the eruption is disposed to deepen from red to purple, T would 
suspend the use of the emollient application, and employ instead the 
lotion of camphorated spirit recommended by Underwood, the campho- 
rated tincture of soap, which I have known to be of great service in the 
erysipelatous inflammations occurring in patients of broken-down consti- 
tution in the hospital of this city, and which is to be applied three or 
four times a day by means of a soft sponge; or lastly, I would make 
trial of Kentish's ointment, a remedy found of great service by my father, 
Dr. Charles D. Meigs, in the erysipelas of children. (North Am. Med. and 
Surg. Journ.y vol. vi. p. 77.) This ointment he prepares by rendering 
basilicon ointment soft (not fluid) with spirits of turpentine. It is 
rubbed upon the inflamed part with the fingers, the anointing being 
" repeated often enough to keep the part always very thinly covered. " 
The internal treatment should consist in attention to the state of the 
bowels, which are to be kept soluble by the mildest laxatives, without being 
purged, and in a resort to tonic and stimulating remedies upon the very 
first approach of symptoms indicating exhaustion. The best remedies of 
this class are proper diet, wine whey, small quantities of brandy, and bark 
in connexion with minute doses of carbonate of ammonia. 
- When the inflammation has gone on to the production of subcutaneous 
suppuration, it becomes still more important to sustain the forces of the 
constitution, by giving the infant a healthy and abundant breast of milk, 
and by the internal use of brandy in small quantities, of bark, or better 
still, of quinine, in combination with small doses of carbonate of ammonia. 
At the same time the suppurating surfaces must be well fomented, and 
dressed with warm poultices, and when necessary, laid open by careful 
incisions, observing the precaution to cause as small a loss of blood as 
possible. If the case occur in a hospital, or in a child placed in un- 
favorable hygienic conditions, let the following statement of M. Barrier 
be borne in mind. " However much the life of an infant be threatened 
by erysipelas, if we can but persuade a wet-nurse to take charge of it, 
the pure air of the country is often seen to replace most advantageously 
all other therapeutical resources." {Loc. cit., t. ii. p. 562.) 

As the preceding remarks have been restricted to the form of the 
disease which occurs in infants under two weeks of age, I have now to 
make some observations on the cases which occur in older children. 

The disease is still, even at this later age, a very dangerous one, though 



G14 ERYSIPELAS. 

much less so, certainly, than in the new-born child. When the subject 
of the attack is a hearty one, we are advised by some to draw blood, 
either by venesection or leeching. I should certainly be very careful of 
following this plan in a child under six months, and were I to resort to 
it at all, it would be only in a very robust and sanguine constitution, and, 
moreover, in a child placed in favorable hygienic conditions. Under these 
circumstances, however, it would doubtless be safe and proper to take a 
small quantity of blood, which had better be done by leeches. The 
leeches ought to be placed at some distance from the eruption, as any 
kind of wound or cutaneous irritation is sometimes found to attract the 
disease. The only internal remedies necessary in the beginning, are such 
laxatives as may be required to keep the bowels soluble when they are 
bound, such as shall correct acidity or diarrhoea when either is present, 
and those which promote an open state of the skin, and a free discharge 
of the urinary secretion. For the latter purpose I know none better than 
the solution of the acetate of ammonia, and the sweet spirits of nitre, 
about ten or fifteen drops of the former, with five of the latter, in sweet- 
ened water, to be repeated every two or three hours. At a later period 
of the disease, when the child begins to emaciate and grow feeble, its 
strength must be carefully supported by the use of proper diet, and of 
stimulants and tonics. The only proper diet is of course breast-milk. 
The best stimulants are five or ten drops of brandy, five drops of aromatic 
spirits of hartshorn, or a quarter or sixth of a grain of carbonate of 
ammonia, in weak syrup of ginger, to be administered four or five times 
a day, or more frequently, when the forces of the child are greatly pros- 
trated. The proper tonic is from a quarter to half a grain of extract of 
bark, or half a grain of quinine, in some proper vehicle, every three or 
four hours. 

The best local treatment is, in my opinion, cooling or tepid emollient 
applications, as slippery elm bark, marsh-mallow, or flaxseed tea, during 
the first few days, whilst the reaction is marked, and the calorification of 
the body high. Somewhat later, when the strength begins to be re- 
duced, and the color of the eruption to deepen, we should make use either 
of mercurial ointment, which is highly recommended by some, or of the 
Kentish's ointment or camphorated tincture of soap, to which attention 
has already been called. I would here propose the trial of an oint- 
ment, which I have found not only soothing and comforting to the child, 
but also of manifest curative efficacy, in the violent cutaneous inflamma- 
tion of scarlatina. It consists of one ounce of fresh cold cream, rubbed 
up with a drachm of glycerine. It should be smeared over the inflamed 
surface several times a day, and need not interfere with the use of 
emollient applications. In scarlatina it has been most useful in reducing 



ROSEOLA. 615 

the burning heat of the eruption, and in softening the harsh and distended 
skin, and by these effects has aided greatly in moderating the severity of 
the general, and especially of the nervous symptoms. 

In children over two or three years of age, erysipelas must be treated 
on the same principles as in adults : by moderate abstractions of blood 
from the arm, by low diet and rest in bed, by the internal use of laxatives 
occasionally, of minute doses of tartar emetic or ipecacuanha, either 
alone, or in neutral mixture, and by the external application of emol- 
lient infusions, so long as the symptoms remain acute, and the strength 
unreduced. But when, after a time, the fever begins to subside, or the 
child begins to show signs of debility and a tendency towards the typhoid 
condition, all exhausting measures must be suspended, and we must en- 
deavor to maintain the life-actions in a proper degree of energy, by a 
more nourishing and abundant diet, by the prudent administration of 
bark or quinine, and even by the use of brandy and ammonia, should the 
strength of the patient be disposed to give way suddenly or rapidly. 
Under these circumstances, moreover, the best local application will be 
either the Kentish's ointment, or the camphorated tincture of soap. 



ARTICLE III. 



ROSEOLA. 



Definition; Synonymes; Frequency; Forms. — Roseola is a non- 
contagious, fugacious exantheme, characterized by rose-colored patches of 
irregular size and shape, which are unaccompanied by elevations or pa- 
pules, and the appearance of which is preceded and accompanied by 
febrile symptoms. 

It is often called in this country scarlet rash, and under that title, 
supposed to constitute a very mild form of scarlatina. It is sometimes 
called also French measles, and roseola sine catarrho. 

Roseola is of rather frequent occurrence amongst children, though 
much more rare than either measles or scarlet fever. 

There are three forms of the disease met with in children, roseola 
aestiva, roseola autumnalis, and roseola annulata. As the two former, 
however, present no differences of any importance, I shall describe them 
under one head, whilst the latter, quite unlike the other two, requires 
that I should describe it apart. 

Causes. — Roseola may occur at all ages of infancy and childhood, and 
at any season, but it is most common in summer and autumn. It has 



C16 ROSEOLA. 

been known to prevail as an epidemic, but has never been thought 
contagious. It may attack the same individual on several different occa- 
sions, one attack not preserving from repetitions. The variolous eruptions 
are sometimes preceded by roseola, and in some children it makes its 
appearance on the ninth or tenth day of the vaccine disease. Of the vari- 
ous causes that I have known to produce it, the most frequent is certainly 
derangement of the digestive function during the first dentition. It is 
said also to be occasioned by sudden changes of temperature, by violent 
exercise, and by the use of cold drinks while the body is heated and 
moist with perspiration. 

Symptoms. — Young children who have been suffering for a few days 
with disorder of the digestive function often exhibit a slight roseolous 
eruption lasting twenty-four or thirty-six hours, and then disappearing. 
The eruption in this mild form of the disease appears suddenly, often in 
the course of a single night, covering the trunk or even the whole surface 
with numerous patches, nearly circular in shape, or in irregular, broad, 
and waving lines, situated close together and yet distinct, and of a light 
rose color. In another and rather more violent form, occurring especially 
during dentition, the eruption appears after vomiting, fever, diarrhoea, and 
slight nervous symptoms, or possibly after slight convulsions, with the 
same characters as just mentioned, except that the rash is deeper in color, 
greater in extent, and that it lasts generally a longer time, — two, three, 
or four days. Again, in a yet more marked form, the roseola sestiva and 
autumnalis, the disease is preceded by certain symptoms which it is im- 
portant to note. It begins with more or less chilliness, alternating with 
heat, with loss of strength and spirits, with headache, restlessness, some- 
times mild delirium, and even with slight convulsive phenomena. At the 
same time there is some febrile reaction, marked by accelerated pulse, 
heat and dryness of the skin, thirst and loss of appetite ; the digestive 
function is shown to be deranged by the presence either of constipation 
or diarrhoea. After these symptoms have continued for two, three, four, 
or even six or seven days, the eruption appears first upon the face and 
neck, whence it extends in twenty-four or forty-eight hours, to the rest of 
the body. The rash resembles very closely, indeed, in some cases ex- 
actly, that of measles. It is in the form of irregularly circular and rather 
large patches, at first of a red, but soon changing to a deep rose color, 
and separated from each other by portions of healthy skin. The erup- 
tion is sometimes accompanied by itching, and sometimes by stinging 
pain, and the febrile symptoms generally continue, though moderated in 
degree, after the appearance of the rash; while in other instances, the 
fever disappears entirely from that moment. The rash lasts between one, 
and two or three days, as a general rule, and fades away gradually until 



SYMPTOMS — DIAGNOSIS. 617 

it has entirely disappeared. In some cases it comes and goes alternately 
for a week after its first appearance. 

Roseola Annulata is a curious and interesting form of the disorder, 
from the singular and beautiful appearance of the bright rose-colored 
rings which constitute the eruption. I have seen but two examples of 
this variety, while I have met with a large number of cases of the other 
forms. It must, however, be of very rare occurrence, since MM. G-uer- 
sant and Blache state that they have never chanced to meet with it, 
though they have seen a large number of roseolous eruptions. (Diet, de 
Med, t. xxvii. p. 626.) 

This variety of roseola appears in the form of rosy rings or circles, 
whose centres retain the natural color of the skin. The favorite seats of 
the eruption are the abdomen, loins, buttocks, or thighs, or it may cover 
the greater part of the body. In one case that I saw, the eruption co- 
vered the face, neck, and trunk. In the other it was seated upon the 
face, trunk, and upper extremities. The rings are at first not more than 
one or two lines in diameter, but they enlarge gradually until their cen- 
tres measure as much as half an inch in diameter. In some instances 
two or three rings surround one another, the skin in the intervals between 
them still retaining, however, its natural appearance. The disease is, 
when accompanied by symptoms of reaction, usually of short duration. 
The cases which occurred to myself lasted only three days, and were ac- 
companied by decided febrile symptoms, together with signs of digestive 
derangement. It sometimes assumes a chronic form, the eruption fading 
in color in the morning, and increasing again and causing heat of skin, in 
the evening. 

Diagnosis. — Roseola sestiva might be readily mistaken by a careless 
observer for measles or scarlatina, especially the former. I have no 
doubt whatever that cases of roseola are often regarded, under the title 
of scarlet rash, as examples of a very mild form of scarlatina, a misappre- 
hension which will explain some at least of the supposed instances of 
second attacks of scarlet fever in the same individual. This is a mistake, 
however, that ought not to occur, and need not, if the following characters 
of the two diseases are properly understood. The rash in scarfatina is, 
in the first place, of a much brighter tint, and it is more persistent and 
more uniformly spread over the surface than in roseola. When we 
come to analyze the characters of the two eruptions, there are other dis- 
tinctions between them which assist greatly in the diagnosis. In scarla- 
tina, the eruption is composed of very large patches, or it is absolutely 
uniform, and evenly distributed over large surfaces, as over the whole 
trunk, or over the flexor or extensor aspects of the limbs. It is seen to 
be composed, too, when minutely examined, of an aggregation of very 



618 ROSEOLA. 

minute red points, which are dotted so closely together, as to present the 
appearance of a general scarlet blush. In roseola, on the contrary, the 
rash is composed of irregularly circular, cresccntic, or waving patches, 
with portions of skin between of a natural or nearly natural color. The 
patches, moreover, are of different tint from that of scarlatina, being of 
a deep rose, instead of a bright red or scarlet color, and they cannot, 
upon close examination, be resolved into the minute dotted points which 
make up the scarlatinous eruption. When we add to these circum- 
stances the facts, that in roseola there is no faucial inflammation, that the 
pulse has not the same frequency almost invariably present even in very 
slight cases of scarlet fever, that all the general symptoms are much less 
strongly marked, that no desquamation takes place in roseola, and that 
the duration of the attack is much shorter, I think we have points of diffe- 
rence between the two, quite numerous and marked enough, to render 
the differential diagnosis easy to a careful observer. 

It has always seemed to me impossible to distinguish with certainty 
between roseola and measles by the eruption alone, and I find that MM. 
Rilliet and Barthez are also of this opinion. (Mai. des En/ants, t. i. p. 
732.) We are told by writers that in roseola the patches composing the 
eruption are more distinct, larger, paler, and more irregular in shape 
than in measles, and that they are separated by intervals of healthy skin ; 
but I am quite satisfied that in some cases witnessed by myself, these 
differences are not sufficient to distinguish them apart. The diagnosis is 
to be made by attention to the following points : by the absence of catar- 
rhal symptoms in roseola, by the slighter severity of all the general symp- 
toms, and by the much shorter duration and greater irregularity of the 
prodromic phenomena, which latter seldom last in roseola more than one 
or two days, and consist of symptoms of gastro-intestinal derangement, 
whilst in measles they last three and almost always four full days, and 
consist of very strongly marked catarrhal or respiratory symptoms, with 
very slight signs of gastro-intestinal derangement. 

Roseola annulata is so peculiar and characteristic in all its appearances 
as to prevent its being mistaken for any other disease that I am acquainted 
with. 

Prognosis. — Roseola is probably never dangerous to life. If it ever 
is so, it must be in consequence of its occurring in connexion with some 
severe internal disease. 

Treatment. — The only treatment necessary in roseola is attention to 
diet j the correction by that means, or, if necessary, by a mild laxative, 
or by some antacid preparation, of the gastric or intestinal disorder; rest 
in bed, or seclusion in a chamber of a properly regulated temperature ) 
and the use of mild diaphoretics and of cooling demulcent drinks. 



URTICARIA. 619 



ARTICLE IV. 



TRTICARIA. 



Definition; Synonymes; Frequency; Forms. — Urticaria is a non- 
contagious exantheme, characterized by hard elevations upon the skin of 
uncertain size and shape, and of a reddish or whitish color, or, more 
frequently, partly red and partly white ; the eruption is generally of short 
duration, is almost always accompanied with intense heat, and violent 
itching and burning, and it is preceded by more or less marked signs of 
gastro-intestinal disorder. 

Its most common title is that of nettle-rash. The mild, discrete form 
of the disease is generally called hives, in the nursery. It is sometimes 
described under the name of essera. It is of very frequent occurrence 
amongst children in a mild shape. I have rarely seen in early life the 
abundant and severe eruption covering the greater part of the surface, 
which is met with in adults. 

The most common form of urticaria in adults is well known to be the 
urticaria febrilis, which is an acute disease of short duration. Two other 
forms of the disease, the urticaria evanida and tuberosa, are occasionally 
met with in adults, though they are both rare. In children, by far the 
most frequent form of the disease that I have seen, is one in which there 
is scarcely any fever whatever, and in which the eruption is very sparse ; . 
the urticaria febrilis is, however, not at all uncommon in early life, while 
on the other hand, I have never met with an instance either of urticaria 
evanida or tuberosa at the age referred to. 

Causes. — Children possessing a fine and delicate skin, especially 
when they are at the same time endowed with a highly nervous tempera- 
ment, are particularly predisposed to attacks of urticaria. The only other 
causes that I am acquainted with are the spring and summer seasons, the 
influence of dentition, derangement of the gastric functions from the use 
of improper food, and lastly, the ingestion of certain articles of diet, 
which have been proven by long experience to be apt to occasion attacks of 
the disease. Of the articles last referred to, those which most frequently 
produce this effect are crabs, the eggs of certain kinds of fish, certain cray- 
fish, and some kinds of smoked, dried, or salted fish. 

Some children are exceedingly liable to the appearance upon different 
parts of the body of a few patches of urticaria. Very slight disturbances of 
the gastric function, a very warm day, and excessive clothing, will occasion 
in such subjects an attack of the disorder ; whilst in many others again, 



G20 URTICARIA. 

the disease is never seen under any circumstances, or only at rare and 
long intervals. 

Symptoms. — The form of the disorder most commonly met with in 
children, in which there is neither fever nor other marked signs of dis- 
order of the general health, is the disease generally described under the 
title of lichen urticatus, but which ought, it seems to me, to be considered 
as one of the varieties of urticaria. This eruption consists of large in- 
flamed papules, which are irregular in shape, being either rounded or 
oblong, projecting most in the centre, and which appear suddenly, with- 
out any or only slight prodromic symptoms. The papules are of a bright 
red color, excepting in their projecting central portions, where they are 
whitish or of a very pale red tint. The eruption is accompanied with a 
smarting and burning pain, and with the most violent and annoying 
itching, which the child endeavors to allay by frequent and often rude 
scratching. It is very fugacious in its character, appearing suddenly, 
lasting for a few hours or several days, and then disappearing entirely, 
or recurring again after a short time in the same or in new places. It 
terminates finally, after from a few days to several weeks, by resolution or 
by a slight furfuraceous desquamation. The most common seats of the 
eruption in children are the face, about the buttocks, or upon the thighs 
or upper part of the arms. 

This is the only form of the disease that I have ever met with in 
infants, and in children under two and three years of age. It is, as 
already stated, of very slight consequence, being merely annoying and 
never dangerous. In young infants it occasions sometimes much crying 
and irritability, which can be explained only by the discovery of the 
eruption. 

The urticaria febrilis is usually, but not always, preceded for a few 
hours or two or three days, by feverishness, and by more or less marked 
signs of gastric disorder, such as nausea, chilliness, headache, and lan- 
guor. In other instances the fever and rash occur at the same time. 
The eruption begins with a sense of itching, and with heat and burning 
of the skin, and soon after there appears on the shoulders, loins, inside 
of the arms, and about the thighs and knees, reddish and solid elevations, 
irregular in outline, but generally roundish or oblong. The latter shape is 
the one the elevations most frequently assume, and it is from the resem- 
blance which they bear in this form to the marks left by the stripes from 
a rod or whip-lash, that they are often called weals. The elevations 
project a good deal above the surrounding surface, forming knots or 
ridges; their size is variable; they have hardened edges; they are 
reddish in color, except over the central and most projecting part, 
which is generally, and always, when the swelling is considerable, whitish 
in its tint; and they are surrounded by a narrow areola of a bright 



SYMPTOMS — DIAGNOSIS — PROGNOSIS — TREATMENT. 621 

red or scarlet color. The amount of the eruption is very uncertain, the 
elevations being sometimes separated by considerable intervals of healthy 
skin, while in severe cases, they are extremely numerous, and from their 
confluent character in such attacks, give to the part upon which they are 
seated, a nearly uniform red color, and occasion at the same time a very 
decided puffing and swelling of the skin. 

The eruption, when at all considerable in degree, is attended with vio- 
lent itching and burning. The former is often so severe and troublesome 
as to occasion the most distressing irritation to the patient, precluding all 
comfort or quiet. It is increased by heat, and especially by that of the 
bed. The patches of eruption which appear first do not continue through- 
out the disease, but, after lasting from a few minutes to a few hours, fade 
away, and are replaced by new and successive crops. During the attack 
the patient is usually more or less feverish, and he suffers from languor, 
loss of appetite, furred tongue, and the usual signs of gastric derange- 
ment. The symptoms subside gradually, so that after a period varying 
from two or three days to a week, the disorder has entirely disappeared, 
leaving behind no traces, except in a few instances, a slight desquamation. 

When this form of urticaria follows the ingestion of certain articles of 
food, the eruption usually appears in a very few hours after the meal, 
being preceded and accompanied by nausea or vomiting, pain and distress 
in the epigastric region, giddiness, headache, and feverishness. 

Urticaria febrilis rarely occurs in very young children. In fact I do 
•not recollect to have seen it under five or six years of age. 

Diagnosis. — There can be no difficulty in recognising a case of urti- 
caria. The peculiar characters of the eruption, and especially the size, 
shape, and color, of the solid elevations of which the patches consist, the 
violent itching and burning which accompany it, and its fugacious cha- 
racter, render it unlike any other cutaneous disease, and ought to prevent 
any mistake as to its real nature. 

Prognosis. — Urticaria is probably never dangerous in children. If it 
be accompanied by symptoms of a threatening or alarming character, 
these are dependent rather upon the gastric disorder, which is the cause 
of the urticaria, than upon the latter affection itself. I have never known 
it to be more than troublesome and annoying. Indeed, as a general rule, 
children are in better health, and enjoy a better digestion, after than be- 
fore the appearance of a nettle-rash. 

Treatment. — There are but two really important indications for the 
treatment of this disease : to attend to the state of the digestive function, 
and to allay, by proper means, the distressing irritation occasioned by the 
itching and burning of the eruption. 

In the mild form of urticaria, called in the nursery " hives/' and in 



622 URTICARIA. 

scientific language, lichen urticatus, the only treatment necessary is care- 
ful regulation of the diet, and the use of means proper to correct any 
evident derangement of the digestive function. The food should be light 
and digestible, but at the same time nourishing. Milk, bread, light 
meats, and the plainest vegetables, form the proper diet for children over 
three years of age. Under that age, milk preparations, bread, and in 
those over a year old, light broths, ought to constitute the diet. In a 
large majority of such cases, no drug whatever ought to be given. The 
only ones likely ever to be required are occasional mild laxatives, when 
constipation is present, and some of the antacids, as very small quantities 
of magnesia or carbonate of soda, or lime water and milk, when the sto- 
mach is acid. To allay the itching and consequent restlessness of the 
child, the patches of eruption should be well and frequently dusted with 
toasted rye or wheat flour, which are often very successful. Washing the 
eruption with salt and water, when the cuticle is not broken, is sometimes 
very soothing, and when the patches are of small extent this may be done 
without any impropriety. Dr. Watson speaks well of a lotion (" first 
recommended by Wilkinson'*) composed of a drachm of carbonate of am- 
monia, a drachm of acetate of lead, and eight ounces of rose water. 

In the urticaria febrilis the treatment must depend upon the cause of 
the attack. When it follows upon the eating of some unwholesome food, 
we must rid the stomach of the offending substance by an emetic, unless 
nature has already caused its rejection by spontaneous vomiting. When 
this end has been gained it will be proper to give some kind of cathartic- 
medicine, the best of which is castor oil, because the mildest and most 
certain, in order to insure the discharge of the whole of the aliment which 
has been causing the mischief. After this the only treatment necessary 
will be the use of cooling and demulcent drinks, containing perhaps a 
little sweet spirits of nitre, rest in bed, or at least seclusion in the house, 
for a few days, and careful regulation of the diet. The latter ought to 
be very light during the continuance of the eruption, consisting merely 
of milk and bread, or of some kind of gruel or plain broth ; after the cessa- 
tion of the disease, it should be augmented only with due care and quite 
gradually. To allay the itching and burning of the eruption, and the 
general distress of the child, the best remedy is a warm bath carefully 
administered. This may be repeated in six or eight hours if necessary, 
and between whiles the surface should be dusted with rye or wheat flour, 
as above recommended. 



ECZEMA. 623 

CHAPTER II. 

VESICLES. 
ARTICLE I. 

ECZEMA. 

Definition; Synonymes; Frequency; Forms. — Eczema is an 
eruptive non-contagious disease, characterized by minute, rather flattened, 
and generally closely aggregated vesicles, seated upon an inflamed surface, 
and usually occurring in somewhat extensive patches. The disease ter- 
minates by the absorption of the fluid contained in the vesicles ; or the 
vesicles open and discharge an abundant serous fluid, which forms thin 
crusts upon the red and inflamed surface, until, after a time, the suppurative 
process ceases, and the eruption disappears with a slight desquamation. 

In children, this disease, in common with impetigo, is often called 
tooth-rash, milky crust, and scald head. 

It is of rather frequent occurrence upon the scalp and face, though 
much less so, according to my experience, than impetigo. 

I shall describe the disease under four heads : eczema simplex, eczema 
of the face, eczema of the scalp, and eczema chronicum. Eczema of the 
face and scalp often presents many of the features of eczema impetigi- 
nodes. 

Causes. — The causes of this disease are, to say the least, very obscure 
in most cases. The only conditions which seem to be clearly ascertained 
as causes, are certain states of constitutional disturbance, such as those 
which occur at the change of the seasons ) disorders of the digestive organs ; 
dentition ; improper diet in infants and children ; and the application of 
irritants of any kind to the skin. The causes, it may be added, of eczema, 
are much the same as those of impetigo, and to the article on that disease 
the reader is referred for more extended information on this point. 

Symptoms. — Eczema simplex may appear upon any part of the cuta- 
neous surface, but is most frequently met with in children upon the face, 
and upon the arms. The eruption appears without any precursory symp- 
toms, and consists of very numerous, closely aggregated, exceedingly 
minute vesicles, containing a transparent limpid serum. After a short 
time the contained fluid becomes turbid, and then milky, and is either 
absorbed, whilst the vesicles shrivel up and disappear by a slight desqua- 
mation, or else the fluid escapes by the rupture of the vesicles, and little 



624 ECZEMA. 

thin scales follow, which are detached before long from the surface beneath. 
The eruption is attended with more or less itching and smarting, but does 
not give rise to constitutional symptoms. The vesicles are generally re- 
newed by successive crops, and the whole duration of the affection is 
usually from two to three weeks, though it may be much longer. 

Eczema of the Face is quite a frequent affection in young children, 
and may exist either in connexion with eczema of the scalp, or it may 
begin upon and remain confined to the face. 

It begins with minute vesicles upon the cheeks or forehead, to which 
parts it may remain limited, or it may extend to the whole face. As the 
eruption appears the skin becomes reddened, and usually rather tense 
and swelled. In a short time the vesicles break and discharge a thin, 
serous fluid, which soon dries into delicate scales. These scales either 
drop off, leaving an inflamed and shining surface beneath, or they remain 
attached, and new effusions of fluid taking place beneath, the crusts are 
increased very much in size and thickness. The eruption may present, 
therefore, various aspects. The skin may appear either inflamed, tense, 
and excoriated and humid, or it may seem to be covered with a very 
delicate, shining epidermis, which is perfectly dry, or presents tiny drops 
of serum or minute cracks; or, lastly, it may be covered with thick, 
lamellated crusts of a yellowish or grayish color, formed by the gradual 
exudation and drying of the discharges beneath the scales first formed. 
When these crusts are detached in the natural course of the disease, or 
by remedial means, the surface beneath is found to be red, inflamed, and 
discharging. The eruption is attended with severe itching and smarting, 
and occasions often much distress and discomfort to the child, breaking 
its rest at night, and rendering it cross and irritable through the day. 

When the eruption is on the decline, the serous oozing becomes gradu- 
ally less and less, the inflammation of the derm diminishes, the crusts 
fall off, and are not renewed, and the disease disappears, leaving, often for 
some time afterwards, a slight redness and scurfiness of the skin. It rarely, 
however, leaves any trace permanent, the part upon which it had been 
seated presenting, after a time, as healthy and as natural an appearance 
as the surrounding surfaces. 

Eczema Capitis. — Eczema of the scalp is often met with in infants 
at the breast during the first dentition, and at later periods of childhood, 
in those who are scrofulous, or who are placed in hygienic conditions 
unfavorable to health. The eruption may be confined to a small portion 
of the scalp, or it may cover the head, and extend to the face and neck. 
It consists at first of disseminated minute vesicles, which break and form 
thin, lamellated crusts, of a yellowish or brownish color. As the disease 
advances the scalp becomes very much inflamed. It is red, tense, swelled, 



SYMPTOMS. 625 

and painful. The vesicles increase in number, and discharge an abundant 
serosity, which hardens into thick yellowish crusts, emitting an offensive 
odor, covering the inflamed surfaces, and matting the hairs together. 
The. disease is attended with violent itching, which is increased by the 
exposure of the head to the air, and which causes the child to scratch 
with such force as to occasion an escape of blood from the irritated and 
excoriated surfaces. 

In some cases, and especially in neglected ones, the disease assumes a 
chronic form. The tissues of the scalp become thickened, and its lym- 
phatic glands enlarged ; abscesses sometimes form beneath the skin ; the 
amount of the secretion diminishes ; and the painful irritation and itch- , 
ing are less troublesome. Under these circumstances the crusts are less 
thick and massive ; they become lighter, thinner, and are more easily 
detached. In such cases the inflammation and suppuration sometimes 
extend to the hair-follicles, and by destroying them, occasion partial loss 
of the hair. * 

Eczema Chronicum. — Eczema often becomes chronic in the child as 
in the adult. The skin, in this form, is either very much inflamed and 
thickened, presenting excoriations with deep cracks and fissures, which 
pour out an abundant ichorous secretion ; or, the inflammation is less 
severe, there being much less heat and redness, fewer excoriations and 
cracks, and a smaller amount of effusion. In the latter condition the 
eruptive surface is comparatively dry, and instead of a raw and discharging 
surface, the inflamed part is covered with thin, yellowish, lamellated scabs, 
or with very fine, minute, whitish scales, which are easily rubbed off, and 
which, in either case, are evidently produced by the concretion of the 
thin, watery secretion, escaping from the part. 

This form is most common about the neck and upper part of the trunk, 
and in the flexures of the joints. It usually lasts for months, and is 
difficult of cure. It is attended with severe itching, which is sometimes 
so troublesome as to occasion the most distressing and uncontrollable rest- 
lessness at night. 

I have met with a number of cases of this kind, and have found them 
very difficult of management. The length of the attack has usually been 
several months. 

Diagnosis. — Eczema simplex, when seated on the hands and between 
the fingers, may be mistaken for scabies. The distinction can be made, 
however, by attention to the following points : the vesicles of eczema are 
flattened, those of scabies are acuminated; in eczema they are always 
agglomerated together, in scabies they are isolated, and entirely distinct ; 
in scabies the vesicles present little red lines running off from their mar- 
gins, and marking the course taken by the acarus ; and lastly, in that dis- 

40 



$26 ECZEMA. 

ease, careful search will almost always enable us to detect the insect, which 
is the characteristic and infallible mark of the disease. 

From sudamina, with which eczema might perhaps be confounded, the 
latter disease may be distinguished by the facts that the vesicles consti- 
tuting sudamina are much larger, that they are discrete and scattered, 
that they are associated nearly always with profuse perspirations, and 
that they are unaccompanied by an inflammatory state of the skin, or by 
itching. 

Eczema of the scalp may be readily mistaken, in severe cases, for 
impetigo of that part, unless care be observed. If, however, careful 
search be made for the elementary lesion in a case, the diagnosis can be 
made with great certainty. This should be sought for on the margins of 
the eruptive surface. In eczema it will of course be a very minute, 
transparent, and flattened vesicle. In impetigo it will be a yellowish, 
prominent pustule. Moreover, even when the elementary lesion cannot 
be readily detected, the appearance of the crusts will usually suffice for 
the distinction. Those of eczema are never so thick, nor are they so 
unequal, irregular, and broken in appearance, as in impetigo. Lastly, 
in eczema there is a much more abundant secretion of serum, which may 
be seen oozing from the inflamed surfaces, or from their margins. 

Eczema chronicum is often somewhat difficult of diagnosis. The erup- 
tion looks rather like a uniform cutaneous inflammation, with cracks 
and breaks in the skin, yielding a thin exudation, than like a true vesicu- 
lar eruption, or it may resemble lichen. The true nature of the disease 
may always be made out, however, by a close inspection of the inflamed 
surface in a good light, or with the aid of a lens. The specific character 
of the eruption is always most perceptible on the edges of the reddened 
surface, for it is at these points that the vesicles are most apt to be found 
in their elementary condition. From lichen it may be distinguished by 
the fact that the surface, when deprived of its crusts, is smooth and 
shining in eczema, while in the former affection, it is rough and papular. 

Prognosis. — The eczema of children is never really dangerous to life, 
though it sometimes occasions much distress to the health by the suffer- 
ing, irritation, and especially by the loss of sleep, which it entails. It is 
often difficult of cure, owing to the fact that it depends on some constitu- 
tional disturbance, or upon some derangement of the digestive system. 
It ought always to be looked upon as the expression of a general disorder, 
or of an internal local disease, and as affording, to some extent, a safe 
mode of evolution of that disease ; and, it should not, therefore, be treated 
by severe topical remedies, since, if suddenly arrested by such means, the 
disease might fall with all the greater severity upon parts more impor- 
tant to life. 



TREATMENT. 627 

Treatment. — The treatment of eczema must depend on the state of 
health of the patient at the time, on the extent and activity of the erup- 
tion, and on its acute or chronic character. 

I have frequently seen small patches of eczema on the cheeks or fore- 
head of young children, which showed no strong disposition to extend. 
Such cases have often been cured with great ease by the application, twice 
or three times a day, of an ointment composed of one part of the Ungt. 
Hydrarg. Nitrat., to two or three parts of simple cerate or lard ; or, I 
have told the mother simply to wash the eruptive patches with cool water 
several times a day, and to anoint them in the evening with ointment of 
cucumbers. 

When the disease is more extensive, and attended with much irritation, 
it is necessary to examine carefully into the state of the digestive function, 
and if this be in any way disordered, to endeavor to restore it to a more 
healthful condition. When the child is teething, the gums ought to be 
examined, and if found swelled and inflamed, they should be lanced 
as often as may be necessary. The diet must be properly regulated, 
the food being changed if that which has been previously taken is found 
not to be well and completely digested. Constipation, if it be present, 
must be overcome by altering the food, or by the administration of 
rhubarb, small doses of magnesia, or sulphur. If the stools are whitish, 
or very offensive, minute doses of calomel, or small quantities of blue pill, 
ought to be given from time to time, until these conditions are overcome. 
So, also, when diarrhoea is present, it should be treated by attention to 
the diet, and by the administration of a weak castor oil emulsion contain- 
ing small quantities of laudanum, when the stools are feculent, but small, 
frequent, and attended with griping. When they are thin and watery, 
greenish, and composed in part of mucus, the following prescription will 
often prove very useful : 

R. — Tinct. Kranierise, gi. 

Tinct. Opii, gtt. vi. 

Sodse Bicarb., 9i. 

Syrup. Zingib., gvii. 

Aqua5, ^ii.— M". 

A teaspoonful two or three times a day, for children of one or two years old. 

In cases of this kind, a few leeches applied in the neighborhood of the 
eruption, from time to time, and the application of compresses wet with cold 
water, or with the decoction of marsh-mallow root or flaxseed, or the use 
of warm bread-and-water poultices, are frequently of the greatest service, 
reducing the heat and irritation, and arresting the progress of the eruption. 



628 ECZEMA. 

When the inflammatory character of the disease has been modified by 
these measures, some application of a kind to alter the mode of action of 
the part ought to be resorted to. Amongst those most frequently useful 
are the following: the ungt. hydrarg. nitrat., either pure or mixed 
"with from one to three parts of simple cerate; cucumber ointment; the 
ointment of carbonate or oxide of zinc; weak tar ointment; sulphur 
ointment ; or a solution of nitrate of silver, of from two to five grains to 
the ounce, to be applied twice or three times a day. 

Chronic eczema must be treated according to the state of the patient's 
health at the time. When the child is weak and debilitated, the diet 
ought to be nutritious and strengthening, but at the same time light and 
of easy digestion. If the blood be thin and impoverished, and the appetite 
weak or capricious, tonic remedies, as tincture of bark, or quinine, with 
one of the ferruginous preparations, ought to be administered. I have 
found it advantageous to give these tonics in a mixture containing a cer- 
tain proportion of compound syrup of sarsaparilla. When the child shows 
signs of a scrofulous or tubercular constitution, small doses of the cod- 
liver oil form the most suitable constitutional treatment. 

If, on the contrary, the patient laboring under chronic eczema is of full 
habit, of gross development, and of florid complexion, the diet ought to 
be so arranged as to lessen the activity of the nutritive processes, and to 
diminish the richness of the blood. A moderate use of cathartic reme- 
dies, as small doses of Rochelle salts, of calomel and rhubarb, of blue pill 
and extract of taraxacum, or of sulphur, ought to be resorted to ; while 
at the same time, small abstractions of blood from the neighborhood of 
the eruption, may be properly directed at sufficient intervals of time. 
When the eruption is very obstinate and of long standing, it is sometimes 
necessary to make use of remedies which have been ascertained by long 
experience, to be efficacious in such cases, and which are said, for the want 
of a better explanation, to modify or revolutionize the constitution. The 
most important of these are mercury, arsenic, tincture of cantharides, 
iodine, iodide of potassium, iron, or cod-liver oil. For my own part, 
I have avoided giving most of these substances, as being too active 
and severe in their effects to admit of their being wisely given to young 
children, except under necessity. The only ones that I have employed 
have been the iodide of iron, and the cod-liver oil. The former I have 
usually given in the dose of two drops, in a quarter or a sixth of a drachm 
of compound syrup of sarsaparilla, three times a day, to children of one 
or two years old ; it should be continued for a period of two or three 
months. The cod-liver oil is another remedy that I have employed suc- 
cessfully, when the child has been in feeble health. My formula for its 
administration is as follows : 



629 
R.- 



TREATMENT. 




01. Jecoris Aselli, 


• 3ss. 


P. G. Acaciae, 


. gss. 


Sacchari, 


. . £i. 


Olei Cinnamom., 


. gtt, vi. 


Aquas Cinnamom., 


. §iii.-M. 



A large teaspoonful to be given three times a day. 

A great variety of local remedies have been recommended by different 
writers. Of those that I have employed, I have found the following the 
most useful : tar water applied with a sponge two or three times a day ; 
citrine ointment, either pure or mixed with from one to three parts of 
simple cerate or lard ; a saturated solution of borax in strong acetic acid, 
used either pure, or diluted to suit the case ; and the following ointment : 

R. — Hydrarg. Protiod., gr. xii. 

Camphorse, gr. v. 

Axungise, !|i. 

To be applied twice a day. 

Amongst many applications that have been used with more or less success, 
I may mention the following : an ointment composed as follows ; 

R.— Hydrarg. Chlor. Mit., . . . . 7)i. 

Camphorce, gr. v. 

Glycerinae, gi. 

Ungt. Aquas Rosae, ; . ; . . ^i. — M. ; 

a solution of nitrate of silver, of from two to ten grains to the ounce, 
applied twice or thrice a day; ointment of carbonate or oxide of zinc 1 } 
weak solution of corrosive sublimate ; sulphuret of potash in lotion ; and 
sulphur ointment. 



ARTICLE II. 

HERPES. 

Definition ; Varieties ; Frequency. — Herpes is a non-contagious 
cutaneous disease, characterized by an eruption of vesicles assembled in 
groups on inflamed surfaces of irregular size and shape, which are separa- 
ted from each other by perfectly healthy portions of skin. The disease 
is usually acute in its course, seldom lasting more than two or three weeks, 
but it is not, as a general rule, accompanied by any severe constitutional 
symptoms. The separate vesicles composing the eruption, last about ten 






HERPES. 



days, and then disappear by the absorption of their contents, by the dry- 
ing up of the contained fluid without rupture of the vesicles, or by the 
rupture of the vesicles, the escape of the fluid, and the formation of thin, 
brownish, or yellowish scabs. 

There are several different varieties of herpes, which have been well 
divided by Mr. Wilson into two groups, the plityctenoid and circinate. 
The phlyctenoid group is characterized by the irregularity of form exhi- 
bited by the eruption, and includes the variety called herpes phlyctenodes, 
and the local forms, called according to their seat, labialis, nasalis, palpe- 
bralis, auricularis, prseputialis, and pudendalis : whilst the circinate group 
is characterized by the arrangement of the vesicles in circles, and includes 
the herpes zoster, circinatus, and iris. Of these different varieties I shall 
describe, as of importance in children, only the phlyctenodes , zoster, cir- 
cinatus, and iris. 

Herpes is quite a frequent disease in children, though one rarely of 
any considerable importance, except in one of its varieties, the circinatus; 
and this is so from its frequency, and not from any danger attending it. 

Causes. — The causes of herpes are often obscure and uncertain, and in 
many cases entirely inappreciable. The disease is most common in per- 
sons who possess a delicate and irritable skin. The most frequent and 
most clearly ascertained cause is some disturbance of the digestive func- 
tions, and, when there exists in connexion with this condition, irritations 
or inflammations of the respiratory mucous membrane, it is especially apt 
to be developed. Herpes phlyctenodes often follows exposure to a hot 
sun, while herpes labialis is frequently caused by exposure to a cold wind, 
especially when this occurs immediately after leaving a heated room. The 
latter variety also frequently accompanies coryza, angina, and stomatitis, 
and appears often as a critical eruption in the course, and particularly at 
the termination, of fevers, catarrhs, and visceral inflammations. 

The usual exciting causes of the disease are irregularities in diet, 
exposure of the body while in a heated state to cold and damp, local 
irritants, and bilious disorders of all kinds. 

Herpes Phlyctenodes. — This variety of herpes, unlike the other 
forms of the disease, may appear upon any part of the cutaneous surface, 
and does not assume a determinate shape. It may appear, indeed, upon 
several parts at the same time. It is usually, however, met with upon 
the upper parts of the body, and particularly the cheeks, neck, chest, and 
arms. It is rare to observe it on the lower extremities. 

I believe it to be a rare affection amongst the children of families in 
easy circumstances. The only examples that I have seen have been the 
result of poisoning by the different kinds of Toxicodendron. 

Symptoms. — The eruption appears in the form of vesicles, usually of 



SYMPTOMS. 631 

very small size, looking like mere points, or attaining sometimes the size 
of a pea, which are seated in groups or clusters on inflamed patches of the 
skin, varying in size from that of a dollar to that of the palm of the hand. 
Sensations of heat, smarting, and itching, are often felt in the part where 
the eruption is about to show itself; and within a day, usually, after these 
symptoms have been observed, or without them, the disease makes its 
appearance, exhibiting one or more red and inflamed surfaces, of an irre- 
gular or rounded shape, dotted over with projecting, globular vesicles, 
which are hard, resisting, and, on the first day, transparent, but which 
become, in the course of a day or two, turbid or lactescent. The red 
color of the eruptive patch generally extends a short distance beyond the 
vesicles : the integument between the different patches retains, however, 
in all cases, its healthy color and character. A sense of smarting and 
itching accompanies, as well as precedes, the eruption. On the second 
day of the eruption, the number of vesicles generally increases, and they 
become full and distended. About the third or fourth day, the vesicles 
have become very turbid, and they begin to shrink. About the seventh 
or eighth day, they are usually transformed, by the drying up of their 
contents, into thin, brownish crusts, which fall off by desquamation about 
the tenth or twelfth day. There always remains, for a few days after the 
disappearance of the eruption, some redness of the surface, which sub- 
sides little by little. 

This variety of herpes is never accompanied by constitutional symptoms 
of any severity. A very slight febrile reaction, some languor, loss of 
appetite, and thirst, are the only ones worthy of note. 

Herpes Labialis. — This is the most frequent of all the varieties of 
the disease. It is, as its name implies, a disease of the lips. Usually it 
is seated upon the line of junction of the mucous membrane with the in- 
tegument ; but it may affect either the former or latter alone. Though 
generally confined strictly to the lips, the eruption, in some instances, 
extends to the cheeks, chin, or ahe of the nose. 

The disease begins generally with redness, heat, smarting, and painful 
tension of the portion of the lip upon which the eruption is about to 
appear. After a few hours, or a day, vesicles begin to show themselves 
upon the inflamed spot, and there is then observed a red, swollen, and 
shining point, upon which is seated a group of vesicles. The tumefaction 
and redness commonly extend some distance beyond the vesicles. The 
latter develope themselves rapidly, until five or six small, rounded vesicles, 
filled with a transparent fluid, are seen. The vesicles remain solitary, or 
several may unite together to form one of considerable size. After the 
complete development of the eruption, the burning pain which existed at 
first commonly subsides. The contents of the vesicles soon become turbid 



632 HERPES. 

and lactescent, and are converted, by the third or fourth day, from a serous 
into a sero-purulent fluid, at which time, also, the accompanying redness and 
swelling have, in great measure, disappeared. Soon after this, brownish 
crusts are formed by the drying up of the fluid of the vesicles; and these 
drop off usually about the seventh or eighth day. A slight redness remains 
for a short time at the point of eruption, and then disappears entirely. 

Herpes Zoster. — This variety of herpes is known also by the names 
of Zona and Shingles. It is of much less frequent occurrence, in this 
city, in children, than either the herpes labialis or circinatus. I have 
never as yet seen a case of it in a child, though Rilliet and Barthez state 
that they met with this form and the herpes labialis more frequently than 
any other. The peculiarity of the disease consists in the fact that the 
eruption appears in the form of a half zone, surrounding half the body, 
whence its name, herpes zoster, the latter word signifying a girdle or belt. 

The most frequent seat of zona is the base of the thorax, the disease 
extending usually, in the form of a cincture, from the mesial line in front 
to the same point behind. It may, however, be developed either above 
or below the part just named, and, under these circumstances, is apt to 
extend towards or down the arm, or towards the thigh and down the 
leg. Still more rarely, it has been observed upon the neck, face, or 
scrotum. There is some doubt as to which side it is most disposed to 
attack. The half zone formed by the eruption is not composed of a con- 
tinuous line of vesicles, but is made up of distinct patches of eruption, all 
following the same general direction, but divided from each other by por- 
tions of healthy integument. The eruptive patches may be very closely 
approximated, or they may be separated by considerable spaces of skin 
untouched by the disease. 

The disease is acute in its character, lasting, as a general rule, from 
one to three or four weeks. 

Shingles appear first, after some previous smarting and burning in the 
skin, in the form of irregular patches of a vivid red color, more or less 
widely separated from each other, and developed, one after the other, 
until one-half the body is girdled by the eruption. In some instances the 
disease appears simultaneously at the two extremities of the zone, and is 
terminated by the gradual formation of successive patches between these 
two points. Soon after the appearance of the inflamed patches, numerous 
small, white projections can be seen, by careful examination, upon the 
red surfaces ; these increase rapidly in size, and are soon converted into 
distinct, transparent vesicles. The vesicles augment in size, and arrive, 
in the course of three or four days, at their fullest development, when 
they are about as large as small or large peas, or, in some few instances, 
much larger. At this stage of the eruption, the red surface upon which 



SYMPTOMS. 633 

each group of vesicles is seated extends a slight distance beyond the patch, 
thus forming a kind of areola. 

After pursuing the course just described during four or five days, each 
group of vesicles begins to subside. The redness of the inflamed patch 
diminishes; the vesicles shrink, and become shrivelled; their contents, 
which were transparent at first, become opaque, and finally they dry up 
and form small, dark-brown scabs, which fall off about the tenth or twelfth 
day, leaving behind reddish spots, which disappear little by little. 

The constitutional symptoms of herpes zoster consist usually of slight 
feverishness, languor, and the signs of some gastro-intestinal irritation. 
The local symptoms are pungent and burning pain at the beginning of 
the eruption, and more or less severe tension, and sometimes acute pain, 
in the part upon which the disease is seated, which latter lasts, in some 
instances, throughout the course of the disorder, or even for some con- 
siderable time after it has disappeared. 

Herpes circinatus. — This variety of herpes has been called also ring 
herpes, herpetic ringworm, and vesicular ringworm. In this country it is 
always called ringworm. It is, according to my experience, much the 
most common form of the disease after herpes labialis. 

The eruption consists, as in all forms of herpes, of small vesicles seated 
upon an inflamed surface. The typical character of the eruption is the 
arrangement of the vesicles — which are very small — upon inflamed surfaces 
disposed in circular rings, whence its name of circinatus. 

Symptoms. — The disease begins with a more or less vivid redness of 
the integument at the point affected. The redness assumes the form of 
a circular patch, which varies a good deal as to its size, being in some in- 
stances small, not larger than a shilling, and in others presenting a dia- 
meter of two or three inches. When small, the redness covers the whole 
of the patch, but is much fainter in the centre than at the circumference ; 
when large, the centre retains the natural color of the skin, and the red- 
ness then takes the shape of a banded ring ; usually, the ring is exactly 
circular, but sometimes it assumes an oval shape. Yery early after the 
appearance of the redness, vesicles begin to show themselves, and soon 
they become numerous and confluent. They are very small and always 
of a globular shape. The vesicles follow the same course as in other 
forms of herpes ) they are at first transparent, then become turbid, open, 
and dry into small thin scales, which fall off generally in eight or ten 
days, leaving beneath a reddened surface, which disappears gradually. In 
some instances the eruption is very slight, and the vesicles, which are 
then excessively minute, disappear by the absorption of their contents, 
and by a scarcely perceptible furfuraceous desquamation. 

As already stated, the disease usually runs its course in about eight or ten 



HERPES. 



days. In some cases, however, it lasts longer, though rarely more than 
two or three weeks, and it is kept up in such instances by the formation of 
successive rings. The eruption may appear upon any part of the body, 
but is much the most frequently met with upon the arms, shoulders, 
neck, and face, and especially upon the two latter. The only symptoms 
accompanying the eruption are slight pricking, smarting, and itching in 
the part. It is, according to Underwood, and such is also my own 
opinion, never contagious. 

Herpes Iris. — This is a very rare variety of herpes, one that I have 
never yet met with in children. It begins with small red spots, which 
are soon surrounded by four or five rings of different shades of redness. 
About the second day of the eruption, the central red spots present in 
their centres one or more vesicles, and on the third and fourth days, 
vesicles of very minute size generally appear on the outer concentric 
rings. After two or three days, the fluid contained in the central group 
of vesicles, which was transparent at first, becomes turbid, and about the 
fifth or sixth of the eruption, it is absorbed, and the disease terminates 
by a slight desquamation. The vesicles formed on the outer ring, undergo 
the same changes as those described as occurring in the central ones. In 
some instances, the vesicles open, and their contents escaping, these form 
small, thin, and brownish scales, which fall off in ten or twelve days. 

Herpes iris may attack any part of the body, but is most frequently 
developed upon the face, hands, fingers, and neck. 

Diagnosis. — The diagnosis of herpes is seldom attended with any diffi- 
culty. The small size of the vesicles, their globular shape, their number, 
their aggregation upon distinct patches of inflamed integument, and the 
slight degree of constitutional disturbance attendant upon the disease, 
all render the eruption unlike any other cutaneous affection, and therefore 
easy of recognition. 

Herpes phlyctenodes might possibly be confounded by an incompetent 
observer with pemphigus. The recollection that the eruption in pemphi- 
gus consists of distinct bullae, much larger of course than the vesicles of 
herpes, while that of herpes phlyctenodes consists of numerous vesicles, 
much smaller than the bullae of pemphigus, and closely dotted over isolated 
red patches, will always serve to distinguish the two affections. It might 
be mistaken also for eczema, when the vesicles of the latter are disposed, 
as sometimes, though rarely happens, in groups. The distinction may be 
made, however, by attention to the facts that the eczematous vesicles are 
redder, less elevated, scarcely transparent, and that, though arranged in 
groups, they are confluent, whilst in herpes they are always distinct. 

Herpes labialis is not likely to be mistaken for any other eruption. 



DIAGNOSIS — PROGNOSIS — TREATMENT. 635 

Herpes zoster may always be distinguished by the peculiar belted form 
assumed by the eruption. 

Herpes circinatus might be mistaken in a certain state of its progress, — 
after the disappearance of its vesicles, for lepra, when the latter has been 
deprived of its whitish scales. In lepra, however, the depression of the 
centre of the ring, and the elevation and hardness of the border, charac" 
ters which are absent in ringworm, will almost always enable us to make 
the distinction. Moreover, the presence of some remains of vesicles 
in herpes, the absence of the eruption from other parts of the body, and 
the early disappearance of the disease, will almost always render the diag- 
nosis easy and certain. 

There is but one disease with which herpes iris is likely to be confounded, 
— roseola annulata. The entire absence of vesicles in the latter affection 
will always, however, enable us to make the distinction. 

Prognosis. — The prognosis of herpes is always favorable. It is never 
in itself a dangerous disease, though the variety called zona often causes 
much suffering, and is moreover usually the expression of a considerable 
disturbance of the general health. 

Treatment. — The different varieties of herpes seldom require more 
than the mildest treatment. In all, attention should be paid to the 
general health. The diet must be regulated according to the state of the 
digestive function. When constipation is present, especially if there be 
some febrile reaction at the same time, gentle laxatives ought to be ad- 
ministered, such as sulphur, magnesia, syrup of rhubarb and magnesia, 
or castor oil. If the skin be sallow, the tongue heavily coated, the 
breath foul, and the stools scanty and light-colored, or very offensive, 
small doses of blue pill in combination with rhubarb, or followed by 
rhubarb and magnesia, would be the most appropriate remedy. Exces- 
sive or frequently-repeated doses of any kind ought to be avoided, as the 
debility and gastro-intestinal irritation that so often follow such practice, 
are more injurious than the original disease. 

The local treatment of herpes is important, and is, indeed, in many 
cases, all that is necessary. 

Herpes phlyctenodes requires nothing more than mucilaginous lotions, 
an occasional warm bath, or the frequent moistening of the eruption with 
a liniment made of equal parts of lime water and sweet oil. Herpes 
labialis, if it demand local treatment at all, may be relieved by the use 
of any mild lip-salve : a very good ointment is one composed of equal 
parts of Goulard's cerate and simple cerate, with a few drops of glyce- 
rine. Mr. Wilson recommends the following ointment : 

R. — Unguent. Flor. Sambuci, 3i. 

Liq. Plumbi, 3L— M. 



636 scabies. 

During the early stage of herpes zoster, the local treatment should be 
such as will tend to allay inflammation and relieve pain. These effects 
may be obtained by applying compresses moistened with some kind of 
mucilage, such as barley water, or decoction of flaxseed or slippery-elm 
bark, or with simple cold water, or with weak lead water and laudanum. 
When the eruption is followed by excoriations or ulcerations, and the pain 
is severe, the latter may be allayed by the use of an ointment consisting 
of equal parts of Goulard's cerate and lard, either alone, or containing two 
or three grains of opium, or half a drachm of the watery extract of opium. 
Underwood recommends, when the discharge has subsided, and the scabs 
have formed and become adherent, that they should be anointed twice 
daily with the ung. hydrarg. ammoniat. 

The local treatment I generally use for herpes circinatus, and it rarely 
fails, is a solution of sugar of lead in distilled water, in the proportion of 
a drachm to the ounce. This is to be rubbed over the herpetic ring two 
or three times a day. Gibert {Trait. Prat, des Mai. de la Peau, p. 162), 
recommends the following ointment, when the disease becomes chronic : 

R. — Calc. Sulphuret., ^i. 

Camphorse, gr. xv. 

Axungige, ^i. — M. 

Herpes iris seldom requires any treatment. If any be determined on, 
it should consist of alkaline lotions, or of water rendered slightly astrin- 
gent by the addition of alum, or sulphate of zinc. 



ARTICLE III. 



Definitions; Synonymes; Frequency. — Scabies is a contagious 
vesicular eruption, in which the vesicles are pointed, generally discrete, 
and from which, as a general rule, run off small red lines, of one or several 
lines in length. It is attended with severe itching, and it is caused 
by the presence in the skin of a small insect, called the Acarus Scabiei. 

It is called also psora and itch. 

It is a frequent disease amongst the children of the poor and needy in 
the large cities of Europe ; but, so far as my observation goes, is rare in 
this city. 

Causes. — Itch is a contagious malady, and is in all probability caused 
only by contact, either immediately with some person laboring under the 
disease, or with articles of clothing worn by an infected individual. 



SYMPTOMS. * 637 

It is much more frequently met with amongst the poor and destitute, 
whose habits are uncleanly, who live closely packed together in small and 
inconvenient houses, and in whom, therefore, the means of communica- 
tion are abundant, than amongst the easy classes of society, whose habits, 
and, consequently, liability to contact, are the opposite of those just named. 

The disease usually appears in children in from four to five days after 
the exposure to contagion. In healthy, sanguine children, it often shows 
itself within a shorter time, — after two days, — while in those who are 
feeble and weakly, the period of incubation may be even longer than four 
or five days. 

Symptoms. — The first symptoms of itch appear in the part to which 
the cause, a contagious contact, may have been applied. In infants at 
the breast, it is usually first developed on the hips and thighs, as it is 
those parts that are most constantly in contact with the nurses who carry 
the child, and from whom young children generally receive the infection. 
In older children, the disease commonly appears first on the wrists and 
between the fingers, and extends thence more or less quickly to the 
flexures o^the elbows, and to the axillae and abdomen. It rarely or never 
attacks the face in adults ; but in children, even this part is not, according 
to M. Richard, exempt. (Trait. Prat, des Mai. des Enfants, p. 590.) 

The disease is always attended with severe itching, which, in infants, 
causes uneasiness and fretfulness, and in older children violent scratching. 
The itching is increased by the heat of the bed-coverings, and is, there- 
fore, most troublesome at night. The eruption appears in the form of 
more or less numerous vesicles, which are small, discrete, acuminated, and 
transparent at the top. The vesicles are at first of a faint rose color, and 
they contain a viscid, transparent serum. Their number is variable, being 
sometimes very abundant, and at others sparse. They either open spontane- 
ously, or are soon broken by the fingers or clothes, and are followed by small, 
thin, slightly adherent scabs. In some instances the action of the nails 
causes slight effusions of blood, which dry into small bloody scabs, like 
those of prurigo, thus embarrassing, to a certain extent, the diagnostic of 
the disease. Sometimes, particularly when the inflammation attendant 
upon the eruption, or caused by scratching, is marked, there are, inter- 
mingled with the psoric vesicles, pustules of impetigo, or perhaps of 
lichen, which tend like the sanguine crusts, just alluded to, to render the 
diagnosis difficult. 

•When a recent vesicle is carefully examined, there may generally be 
observed running off from it, in a straight, curved, or zigzag direction, 
a whitish or reddish line, like that produced by the scratch of a pin. 
This line marks the course of the acarus scabiei in its burrowings under 
the epidermis, and is called the cuniculus, or burrow. It varies in length 



638 SCABIES. 

from one or two, to five or six lines. At the point where it terminates 
opposite to the vesicle, there is usually to be seen a small rounded pro- 
jection, de'eper in color than the rest of the cuniculus, beneath which lies the 
insect. The acarus can often be found at this spot, and removed, by care- 
fully introducing horizontally under the epidermis, the point of a small 
needle, and by manipulating so as to take off a small layer of the epidermis. 
The insect clings to the point of the needle, and can then be extracted 
from its lodgment. 

The number and extent of the vesicles vary greatly in different sub- 
jects. In some they are confined to limited surfaces, while in others, 
and particularly in robust, sanguine children, and in those who are ne- 
glected and imperfectly cleansed, they extend to many different parts, or 
over the greater part of the body. 

Itch occasions in children much irritability and suffering, and when 
neglected may injure seriously the general health, and cause emaciation 
and debility. 

The acarus scabiei is an arachnoid insect, varying, according to Mr. 
Wilson's measurements, between -^ and 7 * 7 of an inch in lungth, and 
between 3^3 and ^ of an inch in breadth. It is of a whitish and shining 
color, when examined with the naked eye, of a globular form, and is pro- 
vided with eight legs, four anterior, and four posterior. A most accurate 
and minute account of the structure of the insect is given by Mr. Wilson, 
in his work on diseases of the skin. 

Diagnosis. — The most characteristic marks of itch are the presence of 
the cuniculi and of the insect which causes the disease. If the acarus can 
be extracted from the skin, there will remain, of course, no doubt ; and if 
the cuniculi be distinct and numerous, the diagnosis becomes almost as 
certain as when the insect itself is obtained. 

When, on the contrary, the insect cannot be found, and when the 
cuniculi are absent or not distinct, the diagnosis becomes more uncertain. 
The diseases with which it is most likely to be confounded are eczema 
simplex, prurigo, and lichen simplex. From the former it may usually 
be distinguished with certainty by attention to the following points. In 
eczema the vesicles are flattened, or globular, scarcely raised above the 
surface, and they are collected together in clusters ; in itch they are acu- 
minated, elevated, and either entirely distinct, or much less confluent 
than in eczema ; in eczema there is a sensation rather of pricking than 
itching, whilst in itch, the sense of itching is severe and distressing j and 
lastly, itch is communicable by contact, whilst eczema is never contagious. 

Prurigo begins with papules which always remain such. The scabs in 
prurigo are small and black, consisting of coagulated blood caused to 
exude by the rubbing off of the top of the papule ; while in scabies the 
scabs are more like thin, yellowish, and friable scales. The seat of the 



DIAGNOSIS — PROGNOSIS — TREATMENT. 639 

two eruptions is different. Prurigo is developed upon the back, the 
shoulders, and upon the extensor surfaces of the limbs ; while itch appears 
first about the thighs and buttocks, between the fingers, or about the 
flexures of the joints. Lastly, prurigo is never, itch always, contagious. 

Lichen simplex is a papular disease, in which the papules are closely 
agglomerated, while scabies is a vesicular affection, with the vesicles dis- 
crete. Lichen sometimes affects the hands, and might then be mistaken 
for itch ; but in the former the eruption affects the dorsal surface of the 
hands, while in the latter it appears in the interspaces of the fingers. 
Lichen is never attended, as itch always is, by severe pruritus. Atten- 
tion to these points of difference will almost always render the diagnosis 
of the two diseases very easy and certain. 

When, as sometimes happens, scabies is intermingled with other erup- 
tions of pustular, papular, or vesicular kind, the diagnosis can be arrived 
at with certainty, only by careful attention to the cuniculi, or by the de- 
tection of the insect. When neither of these characteristic conditions 
are present to mark the true nature of the disease, there will always re- 
main some doubt as to the diagnosis. 

Prognosis. — Itch is a mild disease, which never disturbs the health 
seriously. 

Treatment. — In children, as in adults, the best treatment for itch is 
the use of sulphur by inunction. The ungt. sulphuris of the American 
Pharmacopoeia, consisting of one part of sulphur to two of lard, should 
be well rubbed into the skin before a fire, morning and evening, for two 
days. The child should be kept in a flannel gown, and in bed, during 
this treatment. On the morning of the third day, the skin may be 
washed clean with soap and water, or by immersion in a warm bath. 
This plan rarely fails to effect a cure. Should it happen, however, to 
fail, the treatment must be repeated. 

As the use of the sulphur ointment is sometimes objected to in private 
families, on account of its disagreeable odor, various substitutes have 
been recommended. Mr. Wilson states that he found camphor dissolved 
in oil, in the proportion of one drachm to the ounce, answer every pur- 
pose of eradicating the disease ; and Dr. Coley (Pract. Treat, on the Dis. 
of Children, Phil. ed. 101) speaks highly of an ointment composed of 
a drachm of iodide of potassium to an ounce and a half of lard, of which a 
little is to be applied all over the body, except the head and face, every night. 

The disease rarely requires any constitutional treatment. If, however, 
any complication exist, or the general health be deranged in any way, 
such measures as may be necessary for the removal of either of these 
conditions should be employed, in connexion with those proper for the 
specific disease. 



640 PEMPHIGUS OR POMPHOLYX. 

CHAPTER III. 

BULLAE. 
ARTICLE I. 

PEMPHIGUS OR POMPHOLYX. 

Definition ; Synonymes ; Varieties ; Frequency. — Pemphigus is 
an eruptive disease, characterized by the presence on one or several parts of 
the body, of more or less numerous bullae of considerable size, nearly always 
isolated, resting upon circular or oval erythematous patches about as large, 
or somewhat larger than the bases of the bullae themselves. The bullae 
form in the course of a few hours, and contain at first a limpid serum, 
which soon becomes reddish or turbid ; they terminate by desiccation and 
the formation of thin crusts, or by rupture, and the escape of their con- 
tents, when there remains behind a superficial ulceration. 

Authors formerly described numerous varieties of this disease, and 
gave to some of them the title of pompholyx. Of late years, however, 
these have been reduced to a few forms, and I shall confine my remarks 
to those most apt- to occur in children. The only variety which is really 
important in children is the pemphigus acutus. The pemphigus chroni- 
cus, a dangerous and not unfrequent variety in old people, is so rarely 
met with in early life, as to make it unnecessary for me to describe it* 
Another species of bullar eruption, formerly called pemphigus infantilis, 
is now more properly classed as rupia escharotica, under which title I shall" 
give an account of it. 

Pemphigus is not unfrequently met with in young children who become 
the inmates of hospitals, alms-houses, and foundling hospitals, and 
amongst the poor and destitute classes of large cities. Still it cannot be 
said to be a frequent disease. 

Causes. — The causes of pemphigus are often obscure or entirely in- 
appreciable. It is usually supposed, however, to depend, in children, upon 
the influence of the act of dentition, on disturbances of the gastrointes- 
tinal tube brought about by improper food or over-feeding, and on general 
disorder of the nervous system. It is said to occur sometimes as a con- 
genital affection, and also to be hereditary. 

Symptoms. — Acute pemphigus may be confined to a very small portion 
of the cutaneous surface, or it may affect several regions of the body at 
once. It is usually attended with symptoms of constitutional disturbance, 
which, especially in very young infants, may be slight, consisting merely 



SYMPTOMS — DIAGNOSIS — PROGNOSIS. 641 

of general uneasiness, languor, and some acceleration of the pulse ; or 
they may be severe, exhibiting in such cases a dry and burning skin, fre- 
quent pulse, thirst, and loss of appetite. 

After the above constitutional symptoms have lasted one, two, or three 
days, the eruption makes its appearance in the form of small circular red 
spots, which increase in size, and soon exhibit a bleb or bulla rising in 
the middle or over the whole of the red spot. The vesicle commonly 
appears a few hours after the red patch, and consists of an elevation of 
the cuticle by an effusion of serum beneath it. The bulla rapidly dis- 
tends by the increase of the serous effusion, until it attains the size of a 
pea, a hazel-nut, or a large walnut. It is of a circular or oval form, and 
may be confined to the centre of the erythematous surface on which it 
rests, being surrounded in such case, by a more or less wide red line of 
inflammation, or it may occupy the whole or nearly the whole of the red 
patch, under which circumstances it entirely conceals the latter, or is 
surrounded by a very narrow red ring. The color of the areola around 
the bulla is very bright during the first day of the eruption, while the 
integument between remains perfectly healthy. 

The fluid contained in the bullae soon becomes turbid ; the bullae become 
wrinkled, and usually burst after one or two days, and are replaced by 
thin yellowish or brownish scabs. The crusts begin to form before the 
redness of the integument has disappeared. In some instances the bullae 
do not break, but their contained fluid becomes yellowish in color, and then 
turbid ; it diminishes by absorption, and, at the end of about a week, dries 
into a thin dark-colored scab. The crusts usually fall off in the course of 
two or three weeks, leaving the skin beneath of a reddish color, but in 
other respects healthy. The whole duration of the disease is commonly 
from one to three weeks, the time in each case varying with the mode of 
the eruption ; — when all the bullae appear simultaneously, seldom lasting 
more than one or two weeks ; while in cases in which they appear at 
successive periods, lasting three or even four weeks. 

Diagnosis. — The diagnosis of pemphigus acutus is seldom difficult. 
The large isolated bullae, seated on inflamed patches of the integument, 
filled with transparent serum, and followed by thin lamellated scabs, are 
unlike almost any other kind of eruption. From rupia, the other form 
of bullar disease, it is to be distinguished by the smaller number of blebs 
in the former, by their greater flatness, and by the facts that these are 
followed by true ulcerations, and by thick and prominent scabs. 

Prognosis. — Acute pemphigus is rarely dangerous when it exists 
without complications. When, however, it is very extensive, and accom- 
panied with severe constitutional symptoms, and particularly when it 
exists in connexion with other diseases, or occurs in a child whose health 

41 



642 rupia. 

has been broken down by unwholesome hygienic influences, it may 
assume a dangerous character, and the prognosis should, therefore, always 
be guarded under such circumstances. 

Treatment. — Simple acute pemphigus requires, as a general rule, no 
other treatment than attention to diet, and regulation of the digestive 
function. When constipation is present, this should be overcome by 
means of simple enemata, or by the use of some mild laxative, as manna, 
spiced syrup of rhubarb, or very small doses of castor oil. If the dis- 
charges be too frequent, they should be restrained by the use of opium in 
doses proportioned to the age of the child. In young infants, it will often 
be found that the gastro-intestinal secretions are of an acid and irritating 
character. This condition may be treated with small doses of paregoric 
or laudanum, combined with lime or magnesia water, or with soda. The 
diet must be managed according to the state of health of the child. For 
an infant a good breast of milk is, of course, the best treatment in the 
world. For older children, the diet ought to be light and unirritating, 
but, at the same time, nourishing and strengthening. 

The local treatment should consist, in the early stage, of an occasional 
warm bath. When the bullae have fully formed, they ought to be punc- 
tured, and the fluid gently pressed out, care being taken not to remove 
the cuticle, as this forms the best possible dressing for the inflamed in- 
tegument. When the bullae are followed by excoriations, these may be 
dressed with an ointment, consisting of equal parts of Goulard's cerate 
and simple cerate, made a little soft by the addition of glycerine, or with 
carrot or elder-flower ointment, or with Turner's cerate. 

When the child shows signs of debility during the progress of the 
disease, and also when the eruption tends to assume a chronic course, the 
treatment ought to be tonic and invigorating. It should consist in the 
use of a nutritious diet, and in the exhibition of tonics, as Huxham's 
Tincture of bark, in small doses, quinine, or in the use of wine whey, or 
small quantities of brandy. 



ARTICLE II. 

EDPIA. 



Definition ; Varieties. — Rupia is an eruptive disease, characterized 
in its early stage by distinct, somewhat flattened bullae, of more or less 
considerable size, containing at first a serous, and then a purulent or 



CAUSES — SYMPTOMS. 643 

blackish fluid : at a later period the disease exhibits very thick scabs, 
and still later, ulcerations. 

There are three varieties of this eruption : rupia simplex, rupia promt- 
nens, and rupia cscharotica. The latter variety was formerly described 
under the title of pemphigus infantilis and pemphigus gangj-enosus, and is 
known in Ireland under the different names of white blisters, eating 
hive, and burnt holes. It is the most important variety of the disease in 
young children. 

Causes. — Rupia is most apt to occur in weakly, badly-nourished, and 
scrofulous children, and seems to depend, therefore, upon that state of 
debility and exhaustion of the general health, which results from exposure 
to unfavorable hygienic conditions, which follows exhausting diseases, or 
which exists as a consequence of some bad hereditary taint. 

Symptoms. — Rupia simplex begins almost always on the inferior 
extremities, or more rarely on the trunk or arms, without previous inflam- 
mation, in the form of small, flattened bullae, of about three or four lines 
in diameter. The bullse contain at first a serous and transparent fluid, 
which soon becomes thicker, and is converted into pus. At an early 
period they shrink and become wrinkled, their contained fluid hardens 
and is converted into rough, brownish scabs, which are always thicker at 
the centre than on the edges, and which leave beneath, after their fall, 
superficial ulcerations. These ulcerations either soon cicatrize and 
disappear, or are covered by fresh scabs. After the fall of the final scabs, 
there yet remain, for some time longer, dark brown or livid spots, which 
gradually fade and disappear. 

Rupia prominens exhibits the same general characters as the preceding 
variety, but with more marked and peculiar features. The eruption com- 
mences with a circumscribed inflammation of the skin, on which inflamed 
spot soon appears a bulla filled with yellowish serum, or sometimes with 
a blackish fluid, which rapidly hardens into a brownish or blackish 
wrinkled crust. The crust is surrounded by an erythematous areola, 
formed by the extension of the cutaneous inflammation beyond the circum- 
ference of the scab. Upon this, areola a fresh elevation of the cuticle, by 
purulent deposit, often takes place, which, by its desiccation, adds to the 
size of the crust. This successive increase at the margin of the scab 
enlarges it in breadth, and, at the same time, raises the height of its 
centre, so as to give to it a peculiar and characteristic appearance, and 
causes it to resemble very closely the shell of a limpet or oyster. The 
scabs thus formed usually adhere to the surface beneath with much tena- 
city, and remain attached for a variable, and, as a general rule, conside- 
rable length of time. When at length they fall off, or are removed, there 
are left beneath ulcers of variable depth and extent, which are either 



644 



RUPIA. 



covered by fresh crusts, or, as more frequently happens, they remain 
open, presenting a foul surface of a livid red color, with thickened edges. 
The ulcers are difficult to heal, and, after cicatrization, leave livid or 
purplish stains, which often remain for months. The number of bullae is 
usually small, there being generally one at its height, and one or two 
about to appear, or on the decline. 

Rupia Escharotica. — This variety of rupia, formerly described as 
belonging to the class pemphigus, and then called pemphigus infantilis 
and gangrenosus, differs in some respects from the other varieties of rupia, 
and particularly in the absence of the thick and projecting crusts, which 
characterize rupia simplex and prominens. It occurs chiefly amongst 
cachectic children, appearing usually in the period between birth and the 
first dentition. It is seated generally upon the neck, chest, abdomen, 
scrotum, or inferior extremities. 

The eruption begins in the form of purplish or livid spots, raised 
slightly above the level of the skin. Upon these spots the cuticle is 
soon elevated by a serous fluid, so as to form small bullse, which become 
rapidly larger, until they attain their full size. The bullse are smaller 
than in the other varieties of rupia ; they are irregular in shape, flattened 
on the top, and are surrounded by purplish areolae in the early stage of 
the eruption ) the fluid they contain becomes, at an early period, turbid 
and dark-colored, or almost black. The bullae soon wrinkle, burst, and 
leave ulcerated surfaces, which are painful, often covered with sloughs, 
secreting a sanious and fetid pus, and difficult of cure. 

Soon after the formation of the ulcers, a fresh crop of bullae, forming a 
new eruption, often appears and passes through the same phases as the 
first, thus prolonging and extending the disease. This form of rupia is 
attended with much pain, with fever, sleeplessness, restlessness, and often 
ends fatally from the severe and continued irritation kept up by the 
disease. In cases ending favorably the process of cicatrization is always 
slow and difficult. 

Diagnosis. — Rupia is likely to be confounded only with pemphigus 
and ecthyma. Pemphigus is to be distinguished from rupia by the larger 
size and greater distension and prominence of its bullae ; by the fact that 
the contained fluid of the latter is serous and transparent in pemphigus, 
instead of being turbid and sanguinolent, as in rupia ; by the different 
character of the crusts, which, in pemphigus, are thin and lamellated, 
while in rupia they are thick and rugous ; and, lastly, by the deep and 
unhealthy-looking ulcerations that follow rupia. 

Ecthyma is unlike rupia in being a pustular disease from the first. 
Moreover, the pustules of ecthyma are surrounded by a highly inflamed 
areola, which is not the case in rupia, while the crusts in the former 



PROGNOSIS — TREATMENT. 645 

disease differ from those of the latter in being smaller, harder, more 
irregular, and more adherent. 

Prognosis. — Rupia simplex and prominens, though tedious and slow 
of cure, seldom prove fatal, while rupia escharotica is always dangerous, 
and in very weakly children, especially when these are exposed to bad 
hygienic conditions, very generally ends unfavorably. 

Treatment. — The most important point in the treatment is to attend 
to the hygienic state of the patient. When the child is living in an 
unhealthy house, or a close and confined room, it should be removed, if 
possible, to a more salubrious position, or to a larger and well-ventilated 
room. The diet ought to be such as to invigorate the strength, and pro- 
mote the nutrition of the body. For an infant who is fed upon artificial 
food, or who is suckling a nurse of doubtful health, the best remedy in 
the world is a fresh and full breast of milk. If a nurse cannot be pro- 
cured, the diet should be most carefully regulated, and should consist 
of goats' or asses' milk, if it have been found by previous trial that 
other kinds of food fail to nourish the body properly. While the diet is 
thus attended to, it is necessary to watch the state of the digestive organs, 
and if there be either constipation or diarrhoea, these must be overcome 
by suitable remedies. Tonics and stimulants are always advisable in this 
disease, and may consist either of brandy or wine, given alone, or in con- 
nexion with Huxham's tincture of bark, extract of cinchona, small doses 
of quinine, iron, or any other remedy of this kind that may be preferred. 

Rupia simplex and prominens are to be locally treated in the early 
stage by opening the bullae as soon as they form, and covering them with 
dry lint and a light bandage, or with the water-dressing. The ulcerations 
that follow the bullae may be treated with Goulard's ointment applied on 
pieces of fenestrated lint, and by washing occasionally with lime-water, 
or with weak solutions of alum, copper, zinc, or nitrate of silver. At a 
later period of the disease, when the ulcerations are covered with the 
characteristic thick crusts, these are first to be removed by means of 
poultices of bread-and-water or flaxseed meal, and the surfaces beneath 
them treated with the applications recommended above. When the ulce- 
rations are very obstinate and difficult to heal, they should be modified 
by occasional touchings with nitrate of silver, either pure or in strong 
solution, or with dilute nitric or muriatic acid. 

Billard recommends that the ulcerations should be dusted with pow- 
dered alum or cream of tartar, and Rayer also speaks very highly of the 
last-named application. 

Dr. Stokes found that the best treatment in epidemic rupia escharotica 
was an ointment of the scrophularia nodosa, made by stewing the small 
leaves of the plant in as small a quantity of unsalted butter as may be 



646 ECTHYMA. 

sufficient to prevent their scorching. The ointment is to be warmed until 
it becomes quite thin and then applied by means of a brush, after which 
the surfaces are to be covered with lint smeared with the same ointment. 
The dressing is to be renewed every six hours. 



ii 



CHAPTER IT. 

PUSTULES. 
ARTICLE I. 

ECTHYMA. 






Definition ; Synonymes; Varieties. — Ecthyma is an eruption cha- 
racterized by prominent, rounded, and usually discrete pustules of con- 
siderable size, with hard and inflamed bases. The pustules are followed 
by thick brownish crusts, which leave in their fall a reddish mark, or 
more rarely, a superficial ulcer or a true cicatrix. 

Ecthyma has been called also phlyzacia. There are two varieties of 
the disease to which children are subject, ecthyma vulgare or acutum, and 
ecthyma infantile. 

Causes. — The most frequent causes of ecthyma are the application of 
irritating substances to the skin, such as croton oil and tartar emetic 
ointment, and the presence of other eruptions upon the skin, particularly 
small-pox, measles, scarlet fever, herpes, or scabies. The causes just 
named give rise to the variety called ecthyma vulgare, which, it may be 
well to state in this place, is of an acute character, and has therefore 
been called by some writers ecthyma acutum. The other variety of the 
disease, ecthyma infantile, is a chronic affection, and occurs almost always 
in feeble, badly nourished, and cachectic children, and in those whose 
health has been injured and broken down by exhausting diseases, particu- 
larly by disorders of the gastro-intestinal apparatus. 

Symptoms. — Ecthyma vulgare occurs most frequently on the extremi- 
ties and neck, and more rarely on the trunk of the body. It appears in 
the form of small, red, and circumscribed spots, projecting above the sur- 
face of the skin, hard to the touch, and accompanied by smarting and often 
severe pain, and by soreness on pressure. The centre of the spots is soon 
elevated into a pustule, filled with a purulent fluid. The size of the pustules 
varies, but it is usually about that of half a pea. Each pustule is generally 



SYMPTOMS — DIAGNOSIS — PROGNOSIS. 647 

surrounded by a hard base of a bright red color, constituting an areola, 
while, in some instances, the whole of the red elevation is covered by the 
pustular formation. The pustule remains unchanged usually for three 
or four days, and more rarely for a week, and is then converted by the 
drying up of the effused fluid, into a thinnish brown scab, which drops 
off after a few days, and leaves a congested purple spot that remains for 
some time longer. In other instances, the pustule breaks and leaves a 
small ulceration which terminates with a slight cicatrix. The eruption 
is commonly successive, and is seldom accompanied by any febrile re- 
action. 

Ecthyma infantile is much more frequently met with than the other 
variety of the disease, and occurs in a single, or oftener in successive 
eruptions, in feeble, badly nourished, and cachectic children. It appears 
on the neck, shoulders, arms, and chest, and especially upon the lower 
extremities. It is often connected with some chronic disorder of the 
digestive or respiratory apparatuses, and is developed during the state of 
debility and exhaustion to which children are reduced by those affections. 

The pustules of ecthyma infantile are of variable size, some being small, 
and others as large or larger than a sixpence. They are circular in form, 
and surrounded by an areola of a red or purplish tint ; the fluid which 
they contain is generally not very thick, and is of a dark or sanguinolent 
appearance ; they terminate by the formation of a dark and adherent crust, 
by absorption of the contained fluid and a kind of desquamation, or by a 
bloody excoriation, or true ulceration, which are followed by a deep stain 
upon the skin or a true cicatrix. 

Diagnosis. — Ecthyma is more likely to be confounded with rupia, than 
with any other disease. The pustular character of ecthyma, from the very 
beginning, will, however, almost always enable us to distinguish it from 
the broad and distended bullse of rupia, filled with sero-purulent fluid ; 
and the difference between the two becomes still more marked, when we 
recollect the hard and inflamed bases on which the pustules of ecthyma 
rest, and the shapeless crusts and superficial excoriations of that disease, 
instead of the projecting, rugous, and imbricated scabs, and deep ulcerations 
of rupia. Ecthyma is not at all likely to be mistaken for the small and 
numerous pustules of impetigo, or the umbilicated ones of small-pox. 

Prognosis. — Ecthyma is never a dangerous disease in itself. If any 
danger accompany it, it arises rather from the enfeebled and disordered 
state of the general health under the influence of which it is produced, 
than from any injury caused by the eruption. The prognosis must de- 
pend, therefore, upon the state of the general health existing during the 
attack of the disease. 

Treatment. — In both varieties of ecthyma, attention to the general 



648 IMPETIGO. 

health of the patient constitutes the most important point in the treatment. 
In the acute form, mild laxatives, small doses of some alterative, as the 
hydrargyrum cum creta or sulphur, the use of a nutritious and whole- 
some, and especially of an unstimulating diet, and the local application of 
mucilaginous infusions, or of a mild and cooling ointment, as Goulard's 
cerate, Turner's cerate, or the carrot, cucumber, or elder-flower ointments, 
with occasional warm bathing, are all that the case demands. In the 
ecthyma infantile, the attention of the physician should be directed to- 
wards the restoration of the general health, which, as stated above, is 
always more or less deteriorated. As this deterioration depends usually 
upon the exposure of the child to unwholesome hygienic influences, and 
a consequent unhealthy state of the digestive and nutritive functions, 
it is of primary importance that these should be early attended to. The 
patient ought to be placed in a healthy and well-ventilated apartment; 
the clothing must be regulated according to the age of the child, and the 
season of the year; and, what is most important of all, the diet ought to 
be such as is digestible, suitable to the age, and, at the same time, 
nourishing and strengthening. The internal remedies must consist of 
tonics in all cases, and when the digestive power and general strength are 
reduced much below the normal standard, of stimulants. The best stimu- 
lant is old and pure brandy, either given mixed with water, three or 
four times a day, or combined with the food. The best tonic, in most 
cases, is some preparation of iron, and the one I prefer is the iodide, given 
mixed with syrup of ginger, or, when the bowels are not too irritable, 
with small quantities of the compound syrup of sarsaparilla. When, for 
any reason, iron is not given, quinine, or extract of cinchona, may be sub- 
stituted. While these remedies are being employed, or prior to their ad- 
ministration, the gastro-intestinal functions ought to be carefully regu- 
lated, by the use of mild laxatives when the bowels are constipated, or, 
by some kind of astringent when they are loose and disordered. 

The external or local treatment must consist in the use of mild demul- 
cent applications, or of soothing or cooling ointments, during the pustular 
stage of the eruption. When unhealthy excoriations or ulcerations follow 
the pustules, these may be brought into good condition by the employ- 
ment of weak solutions of nitrate of silver or sulphate of zinc, or of a 
very weak lotion of nitric or muriatic acid. 



ARTICLE II. 

IMPETIGO. 



Definition; Synonymes; Varieties; Frequency. — Impetigo is a 
non-contagious, sub-acute inflammation of the skin, characterized by an 



causes. 649 

eruption of one or more crops of small, yellow, hemispherical, and flattened 
pustules. The pustules are disseminated, or collected in clusters, and 
end, by the drying up of their contents, in thick, rough, and yellowish 
scabs. 

Impetigo has been called also psydracia, melitagra, and crusted tetter, 
or scall. When seated upon the scalp, it is often called by the English 
milky-crust or milk-crust, crusta lactea, tinea lactea, and porrigo larvalis, 
and by the French, crotite de lait, gourme, and impetigo larvalis and 
granulata. 

There are, in reality, but two specific varieties of the disease, impetigo 
figurata, and impetigo sparsa, so named from the manner in which 
the pustules forming the eruption are arranged. From the greater fre- 
quency and severity of the disease, however, as it appears upon the scalp 
in young children, it has become customary to describe it, when seated 
upon that part, under different titles. What constitutes impetigo figurata 
upon the general cutaneous surface, becomes, when seated on the scalp, 
impetigo larvalis or capitis, whilst the impetigo sparsa of the general 
integument receives, upon the scalp, the title of impetigo granulata. 
Though I do not believe that there are any other important differences 
between impetigo larvalis and granulata, and impetigo figurata and sparsa, 
than those of seat, degree of severity, and frequency of occurrence, I deem 
it best to describe them separately, for the reasons that it is most custo- 
mary so to do, and because the disease as seated in the scalp is much more 
frequent, severe, and difficult of cure, than when situated elsewhere. 

Impetigo capitis is one of the most common eruptions to which children 
are liable. Setting aside, indeed, the eruptive fevers, and roseola, it is 
probably the most frequent of all. Impetigo figurata and sparsa of the 
body and limbs are not at all rare, though much less frequently met with 
as distinct eruptions, than impetigo capitis. 

Causes. — The causes of impetigo, like those of most other eruptions, 
are very imperfectly understood. The only one which seems to be at all 
satisfactorily determined is the influence of the process of dentition. Cer- 
tain it is that most of the cases of the disease occur during either the first, 
or the early part of the second dentition ; but wherefore this particular 
part of the evolution of the organism should give rise to the development 
of impetigo, is, to say the least, very imperfectly explained. 

Impetigo capitis or larvalis is, more clearly than the other varieties, 
connected with dentition. Of twenty cases of this form of which I have 
kept a record, nineteen began either just before, or some time during the 
evolution of the milk-teeth, and the remaining case occurred during the 
early part of the second dentition. Writers have enumerated various 
other causes as apt to give rise to this form of impetigo, and particularly 



650 IMPETIGO. 

the lymphatic temperament, deteriorated general health, the scrofulous 
or tubercular diathesis, and exposure to unhealthy hygienic conditions, 
as want of cleanliness, insufficient or improper food, and crowded or ill- 
ventilated habitations. Others, again, and especially Underwood, Wilson, 
MM. Rilliet and Barthez, and MM. Cazenave and Schedel, state that it 
occurs as well in healthy and robust as in weakly and scrofulous children ; 
and this, I may remark, agrees with my own experience, since, of the 
twenty cases above referred to, in only eight was there an unquestionable 
tubercular taint to be found in the parents, whilst in twelve the health of 
the parents was good and strong. My own experience proves, also, that 
want of cleanliness and unfavorable hygienic conditions are not necessary 
elements in the causation of the disease; for all of the twenty cases 
referred to occurred in children who had every advantage of good nursing 
and care that ease of circumstances, and even wealth, could give. I have 
been inclined at times to suppose that artificial diet, either alone, or 
employed in connexion with nursing, has been one of the causes of the 
disease. Upon examining my record of cases, however, I find that of 
sixteen cases in which the kind of diet in use at the time of the appear- 
ance of the eruption was carefully noted, in ten artificial food was partly 
depended upon, while in six the child was confined to the breast alone, — 
a difference insufficient to allow of the conclusion that the use of artificial 
food has any paramount influence in the production of the disease. Never- 
theless, I am disposed to believe that the use of artificial food early in 
infancy, by disordering the digestive function, and rendering the process 
of dentition more difficult and perturbed, may be regarded as one of the 
causes of the disease. 

Symptoms. — In my account of the symptoms of impetigo, I shall 
describe first the variety of the disease which is the most important from 
its frequency, extent, and severity. This is the impetigo larvalis or 
capitis. 

Impetigo Larvalis differs greatly, in different cases, as to its extent 
and intensity. In some children the eruption is confined entirely to the 
face, or to portions of the face, constituting the impetigo figurata of that 
part, or it may be confined to the scalp alone ; or, again, it may attack 
the whole scalp, the face, ears, and neck, and may be associated, as I 
have seen it, with severe and extensive impetigo figurata of the upper 
part of the trunk of the body, of the greater part of the upper extremities, 
and even of portions of the lower extremities. It may be very acute in 
its character, attended with severe and painful inflammation of the integu- 
ment, or it may be subacute ; or, lastly, it is sometimes so mild as to 
produce scarcely any irritation of the part upon which it is seated. 

When mild in its features, it consists of an eruption of numerous small 



SYMPTOMS. 651 

pustules, spread over certain portions of the scalp, to which it may remain 
limited ; or it may cover at the same time, or it may attack alone, the 
forehead, temples, and perhaps portions of the cheeks. It is attended, 
under these circumstances, with very slight redness and heat of the 
integument. The pustules discharge their fluid contents, and form thin 
crusts, which gradually fall off, leaving slightly reddened or excoriated 
surfaces, which soon disappear, or are followed by fresh crops of pustules, 
destined to pass through the same changes as the preceding ones. 

In more severe cases the disease may be confined either to the scalp or 
face, or it may, as stated above, exist upon both simultaneously. The 
eruption presents different appearances in these two situations. 

On the scalp, the eruption may be either partial, or general. It usually 
attacks but a small surface at first, and extends thence gradually to the 
surrounding parts. The pustules are yellowish-white in color, very nu- 
merous, of small size, and attended with heat and itching. They soon 
open or are torn by scratching, and discharge a thick and viscid fluid, 
which glues the hairs together and hardens into uneven brownish-yellow 
crusts. If the scalp is not kept clean by constant washing, or by emol- 
lient applications, the crusts increase rapidly in thickness, by successive 
discharges of fluid from the pustular surface beneath, until at length the 
whole of the diseased part is covered with thick, heavy, rough, and adhe- 
rent crusts, of a brownish or yellowish- white color. When neglected, the 
crusts become more and more thick, and from the heat of the head and expo- 
sure to the air, they undergo partial decomposition, and exhale a fetid, sick- 
ening odor, of the most disgusting kind. Amongst the children of the poor 
and destitute, lice often form in abundance and add to the repulsive cha- 
racter of the disease. At first, the crusts are somewhat soft and moist, 
from the percolation through them of the fluid exhaled beneath, but, as 
they become more abundant and thicker, their outer surface becomes dry 
and sometimes very friable. The secretion from the inflamed surfaces 
often makes its way under the crusted mass above, and, flowing down over 
the forehead and behind the ears, irritates the parts that were before 
healthy, and thus extends the disease. 

When the crusts are removed by any means, the surface of eruption 
is found to be red, shining, wet, and discharging an abundant purulent 
and sero-purulent fluid, which escapes from minute excoriated points dot- 
ted thickly over the inflamed scalp. The integument is, at the same time, 
often tumefied, and tender to the touch. When the disease has lasted a 
considerable length of time the inflammatory action extends to the hair- 
bulbs, and occasions often partial loss of the hair over larger or smaller 
surfaces. This kind of alopecia is never, however, permanent. The hair- 



652 IMPETIGO. 

bulbs are not destroyed, but merely inflamed, so that the hair grows again 
after the cure of the disease. 

On the face, the disease usually shows itself first on the forehead and 
cheeks, to which parts it may remain limited, or whence it may extend to 
the lips, chin, ears, and neck. The nose and eyelids are seldom attacked, 
though I have occasionally seen the upper eyelids slightly affected. The 
eruption begins in the form of pustules, whose development is attended 
with severe pruritus. The pustules are sometimes very small, acuminated, 
and more or less closely aggregated together, and they give rise, by their 
rupture, to thin lamellated crusts ; while in other cases, they are large 
and are followed by much thicker and larger crusts. When the pustules 
are very numerous and large, the accompanying inflammation severe, and 
the discharge copious, and when the formation of the crusts is not inter- 
fered with by topical applications, or by the scratching of the child, large 
portions of the eruptive surface become covered with thick, brownish, or 
brownish-red crusts, which present the general appearance of a mass of 
incrustation, broken by cracks and fissures into portions of very irregular 
size and shape. When the crusts are removed by any cause, the skin be- 
neath appears red, inflamed, and wetted with a more or less abundant sero- 
purulent fluid, sometimes mixed with blood, that oozes from numerous 
small points on the excoriated and inflamed surface. The eruption is 
attended with severe itching, to gratify which the child often tears the 
affected surface with the nails, so as frequently to remove the crusts, 
wound the skin beneath, and cause more or less bleeding from the part. 

Impetigo larvalis, whether confined to the scalp or face, or existing on 
both parts at once, causes, when it exists in the acute form, much distress 
and annoyance to the child. The heat and tension of the part, and par- 
ticularly the itching, occasion much restlessness and irritability 3 they 
make the child cross and peevish, disturb its sleep, and often cause slight 
febrile attacks, which debilitate and injure the health. In other cases, 
however, the general health remains perfect, — all the functions of the 
body going on perfectly well, notwithstanding the local distress and irri- 
tation. The lymphatic glands situated behind and in front of the ear, 
and those on the back and front of the neck, often inflame, enlarge, become 
hard and painful to the touch, and, in a few instances, suppurate, though 
the latter occurrence is not frequent. 

The duration of impetigo larvalis is very variable in different cases. 
Mild cases, and particularly those in which the eruption is confined to a 
limited extent, often get well, or are readily cured, in two or three months. 
When, on the contrary, the disease is severe and extensive, the duration 
is much longer, seldom less, according to my experience, than several 
months, or even one or two years. In most cases, however, the intensity 






SYMPTOMS. 653 

of the disease varies from time to time, so that at one period it may seem 
to be subsiding rapidly, or it may even disappear almost, or be very 
greatly ameliorated, only to break out again with renewed violence under 
the influence of some exciting cause, as the cutting of new teeth, some 
change in the weather or season, or some alteration in the health of the 
child which cannot be explained. 

This variety of impetigo is, as already stated, almost entirely confined 
to the age of dentition. Of the 20 cases of which I have kept a record, 
19 occurred some time during the first, and one during the early part of the 
second dentition. The disease often begins some months before the 
appearance of the first teeth, and, though it generally ceases, or is cured 
before the termination of the dentition, I knew it in one case to run on 
unchecked three months after the conclusion of that process, and then to 
be removed only by medical treatment. 

Impetigo granulata is another form of the disease which is met with 
quite frequently in children during the first dentition. It begins with 
small yellowish-white pustules, developed singly, or in small groups, 
on the crown of the head alone, or scattered over the whole scalp. Most 
of the pustules are formed at the base of the hairs, and are pierced 
by the latter. They are accompanied by more or less inflammation, heat, 
and itching. After a few days, — two, three, or four, — the pustules break, 
and discharge their fluid contents, which concrete into dry, friable, 
brownish crusts of irregular shape, some of which are very adherent, 
matting together a larger or smaller number of hairs, while others are 
broken into small and dry fragments, and in this shape are dispersed 
amidst the hair. Not unfrequently, from the rubbing of the head against 
the pillow, and from scratching with the nails, the scabs are torn off, the 
pustular points are irritated, and slight furuncular inflammations take 
place, which add very much to the annoyance and distress caused by the 
eruption. In other cases, small oozings of blood take place from the 
above causes, and there are interspersed amongst the brownish-yellow 
scabs proper to the disorder, others which result from the coagulation of 
the eflused blood. 

This is a slight disorder in comparison with the impetigo larvalis, and 
is usually much more under the control of remedies, and of much shorter 
duration. 

Impetigo Jigurata occurs most frequently on the face, either alone, or 
in connexion with impetigo of the scalp. I have seen it also, in seven 
cases, seated upon the arms and forearms, and, in a slight degree, on the 
upper parts of the trunk of the body, and on the inferior extremities, in 
connexion with impetigo larvalis. I have met with five cases of this 
form of the disease in which the head was entirely free from it. Three 



654 IMPETIGO. 

of the five children were past the age of the first dentition. The seat of 
the disease is variable. In one, a boy ten years old, it was on the outside 
of the right thigh ; in another, nine years old, on the left arm, at the 
point where a re vaccination had been performed ; in a third, in a boy 
five years old, on the front of the right leg, above the ankle ; in a 
fourth, in a child two years old, on the left anterior side of the thorax, in 
the neighborhood of an abscess ; and in a fifth, in a child a year and a 
half old, on the left leg, just above the ankle. 

The appearances presented by impetigo figurata of the face have already 
been described under the head of impetigo larvalis. When seated on 
the trunk or limbs, the eruptive surface is usually large. On the upper 
limbs I have seen it extend from the shoulders to the hands, and, as a 
general rule, it has been most severe on the outer portions of the limbs. 
On the trunk and lower extremities it has usually affected surfaces of 
much less considerable size, and has commonly appeared in a patch of an 
irregularly oval shape, and of four, five, or six inches in diameter. 

Impetigo figurata of the trunk and limbs presents much the same 
appearances as those already described in my account of impetigo of the 
face. The eruption begins with small, slightly projecting, and closely 
agglomerated pustules, developed upon red and inflamed patches of varia- 
ble size. The pustules usually break in from one to three days after 
their formation, and discharge a purulent fluid, which, if not removed by 
washing or by topical applications, soon hardens and forms more or less 
thick, yellowish, friable, and semi-transparent crusts. If undisturbed, 
the crusts grow thicker by constant additions of fluid from beneath. 
When removed, the surface beneath is found red, inflamed, shining, 
or excoriated, and giving issue from numerous minute points, to a very 
abundant sero-purulent fluid. In long-lasting cases, the integument 
becomes thickened, hardened, and cracked or fissured, so as to present to 
the eye the appearance of a most violent and painful inflammation. 
When the disease tends to recovery, the crusts drop off, the discharge 
diminishes in quantity, so that any subsequent crusts that may be formed 
are thinner than the earlier ones ) at last the discharge ceases, and there 
is left merely a red and shining surface, covered with a very delicate 
epidermis, which long remains in this state, to return, however, finally, to 
the natural condition, or, the diseased action may be rearoused, by even 
slight irritations. 

Throughout the course of the eruption there is much heat, tension, and 
evident smarting and itching at the diseased point. In young children 
these give rise to a great deal of suffering and irritability, and to the 
most violent scratching, such as to cause in many instances large excoria- 
tions, with oozing of blood. 



SYMPTOMS — DIAGNOSIS — PROGNOSIS. 655 

Impetigo Sparsa. — This is quite a common eruption in children of 
all ages. Like the other varieties of the disease, it is most apt to occur 
either during the first or second dentition, and particularly the former. 
It differs from impetigo figurata in the arrangement of the pustules, 
which, instead of being confluent or grouped closely together, are discrete 
or distinct. 

Impetigo sparsa may appear upon any part of the body, but is most 
frequent, according to my experience, about the face and scalp, and espe- 
cially about the mouth. Some writers state that it attacks the extremi- 
ties most frequently, particularly the legs, and that it usually selects the 
flexures of the joints. The eruption begins with small yellow pustules, 
seated upon an inflamed base, and attended with more or less itching. 
The pustules soon break and discharge a sero-purulent fluid, which har- 
dens into a rugous, more or less projecting, friable crust, seeming to con- 
sist of different layers superimposed one upon the other. When the 
crusts fall, or after their removal by topical means, there remains beneath 
an inflamed surface, which may be either excoriated, giving issue to addi- 
tional fluid and a renewal of the crusts, or dry, and disappearing little by 
little, by the gradual fading away of the red color of the spots. 

Diagnosis. — The diagnosis of impetigo is seldom attended with any 
difficulty. The existence of numerous small pustules, seated upon an in- 
flamed surface, and followed by thick, yellow, matted crusts, will almost 
always enable us to recognise the disease with great ease. When there 
is any doubt, a careful examination of the eruption at its outer edge, will 
usually reveal the primary character of the disorder, in the form of well- 
marked yellow pustules. 

From eczema it may be easily distinguished by the presence in that 
disease of vesicles instead of pustules, and by the difference in the crusts, 
which, in eczema, are thin, scale-like, and laminar, instead of being thick, 
rugous, and projecting, as in impetigo. Impetigo larvalis is readily dis- 
tinguished from porrigo favosa, by the facts that the pustules of the latter 
disease are imbedded in the epidermis, that the crusts of porrigo present 
a peculiar bright yellow color and are of an umbilicated or cup-like shape, 
and that the favose disease is followed by incurable alopecia, and is conta- 
gious, in all of which circumstances it differs entirely from impetigo. 

Prognosis. — Impetigo is very rarely a dangerous disease. I have never 
met with a fatal case in my own practice. In one instance, however, that 
came under my observation, of very severe impetigo larvalis combined 
with extensive impetigo figurata, in a child a few months old, the disease 
ended fatally some weeks after the child had been put under the charge 
of a homoeopathic practitioner. But, though not dangerous, there are 



656 IMPETIGO. 

few diseases so distressing to the patient, and so annoying to the attend- 
ants, as a severe impetigo of the head ; and, when combined with exten- 
sive impetigo figurata of the limbs and parts of the trunk, it constitutes 
a serious and important disorder, from the very great suffering, irritability, 
restlessness, and sleeplessness, which it occasions. 

In the prognostic given by the physician, especially in the instance of 
extensive impetigo, he should never forget to refer to its probably long 
duration, and to its disposition to return even after an apparent cure 
has been made. It often lasts many months, and sometimes one or two 
years, or even longer. 

Treatment. — It is well known to most physicians that it has long 
been supposed by many persons, both in and out of the medical profession, 
that the attempt to cure impetigo in children, and especially in infants, is 
often attended with serious risk to the health, and even life, of the patient. 
This notion is grounded on the supposition that the cutaneous disease is 
an effort of nature to prevent some constitutional or inherent local dis- 
ease, an idea which has been strengthened, and maintained, by the occa- 
sional occurrence of examples, in which the sudden cure of impetigo is 
said to have been followed by dangerous and even fatal symptoms. To 
give the various opinions held by different writers on this point, or to 
discuss at length a subject upon which so much might be said, would, 
however, carry me much beyond my proper limits, and I shall therefore 
rest content with stating the conclusions to which my reading and my 
own experience have led me. 

I believe it unsafe to procure, by the employment of external means, a 
very rapid desiccation and removal of an extensive impetigo, as the sudden 
arrestation of so large a secretion as that which is always going on from an 
extensive eruption of this kind, could scarcely fail to be followed by bad 
consequences. That consequences of this kind do sometimes occur from 
such an event, there can be no reasonable doubt, since it is asserted by com- 
.petent observers, since it is a received opinion amongst many respectable 
practitioners, and since dangerous symptoms have been known to follow 
the sudden disappearance of other long-continued discharges. But, 
though I believe it to be dangerous to cause a sudden disappearance of 
extensive impetigo by active external means, I at the same time believe 
that those who entirely neglect impetigo on the ground of its being a 
useful and beneficial disease, and allow it to run on to any extent and for 
any length of time unchecked, are almost, though not quite so much in 
the wrong, as those who treat it with over-much activity. Any one who has 
watched a child laboring under impetigo larvalis and impetigo figurata of 
the limbs combined, and who has heard the accounts given by the mother 



TREATMENT. 657 

or nurse of its sufferings, its dreadful itching, its restlessness, crying, 
sleeplessness, its attacks of disordered digestion, its swelled and perhaps 
suppurating lymphatic glands, and who will try to form to himself some 
idea of the torments such a child must have undergone in the months' or 
years' long duration of such a disease, will, I am sure, feel himself en- 
tirely justified in the attempt to remove the malady by the use of any 
safe means that may offer. Moreover, I am myself convinced that vhere 
the disease lasts in an aggravated form for a year or two, it sometimes in- 
jures, seriously, the strength of the constitution. In one case, that came 
under my own observation, there remained, after the disease had lasted 
two years and a half, a chronic bronchitis, which had begun during the exist- 
ence of the eruption, and which appears to be incurable, as it still persists, 
though it is ten years since the impetigo was cured. In another instance, 
with the history of which I am acquainted, a bronchitis set in during a 
most severe impetigo lasting several years, and in this case also the 
bronchitis has become chronic and incurable. The subject of the latter 
case was one of a family of three children, and whilst the other two chil- 
dren, who had no disease of the kind, are robust and healthy adults, 
the child who had suffered so long and so much with impetigo, has grown 
up a comparatively weak and delicate person, never without cough and 
abundant catarrhal expectoration. 

I am therefore clearly of opinion that the impetigo of children ought 
to be treated, but always with care, and in such a manner as to avoid a 
rapid cure of extensive and confirmed cases, by external desiccating reme- 
dies. "When the disease is of small extent, and when the first and most 
acute stage has passed by, I can imagine no objection to a careful em- 
ployment of the class of remedies just alluded to. In no class of cases 
can I find any valid objections to the use of constitutional remedies at 
any period of the disease, if such are chosen as are known to be safe 
in themselves, and if they are used with due regard to the existing 
state of the patient's health. 

Mild cases of impetigo, such as the impetigo sparsa and impetigo figu- 
rata, of limited extent, commonly yield readily to treatment. The appli- 
cation of a soft bland poultice for a few hours every day, or of some 
emollient decoction, as that of slippery-elm bark, marsh-mallow root, sas- 
safras pith, or bran-water, or the use of warm chamomile infusion, on com- 
presses covered with oiled silk, in order to remove the scabs, and after 
this, the use of some of the alterative or soothing ointments or lotions, 
will almost always effect a cure in the course of several days or a few 
weeks. Amongst the remedies that I have found most efficacious after 
the removal of the crusts, is an ointment composed as follows : 

42 



658 IMPETIGO. 

It. — Glycerinse, ^ss. 

Ungt. hydrarg. nitrat., 3iss. 

Cerat. simp., £ii. — M. 

To be applied twice or three times a day. 

Or, the citrine ointment may be used pure or nearly pure, when the case 
is somewhat chronic and obstinate. An ointment consisting of one part 
of flowers of sulphur rubbed up with two or three parts of fresh and 
sweet butter, is also a very good one. When these fail, and also when 
there is much oozing from the eruptive surface, the Turner's cerate or 
the ungt. zinci oxid., will often prove useful. Lotions of weak lead- 
water, of diluted chloride of soda wash, or a very weak corrosive sublimate 
solution, may, if necessary, be substituted for the ointments, when the 
latter fail or seem to irritate. 

The treatment of impetigo larvalis must depend upon the stage and 
extent of the disease, and upon the state of health of the child at the 
time. In an acute, and especially in a very extensive eruption which is 
discharging copiously, it is not proper, as already stated, to attempt a 
sudden cure by means of irritating or drying external applications. 
When, on the contrary, the eruption is confined to a small surface, and 
when not very acute and rapid in its progress, we may safely employ 
remedies intended to arrest it, and amongst the best of these are the 
lotion recommended for eczema, consisting of one part of acetic acid nearly 
saturated with borax, and mixed with five or six of water ; citrine oint- 
ment, either pure or diluted with one or two parts of lard; the zinc 
ointments ; or a solution of corrosive sublimate, containing half a grain 
to the ounce, and applied by washing the diseased surface twice or three 
times a day, for several minutes each time, with a rag wet with the 
solution. 

When impetigo is extensive, either covering the head and face alone, 
or extending also to the limbs, we are cut off, by the dangerous effects 
they are said to produce, from the use of active or drying external means. 
In such cases I have been accustomed, for several years past, to depend 
more on general than topical means, and as the remedies I usually employ 
are such as tend to invigorate the general health, and are in themselves 
safe, I have no hesitation in recommending them. The two remedies 
from which I have obtained the best effects are iodide of iron and cod- 
liver oil. The former I have generally given in combination with com- 
pound syrup of sarsaparilla, in the dose of from one to three drops diffused 
in from a quarter to half a teaspoonful of the compound sarsaparilla syrup 
three times a day, for children of one or two years of age. I have never 
witnessed any unpleasant effects from the iron. The syrup of sarsaparilla 






TREATMENT. 659 

has sometimes acted as a purgative. If the cathartic operation be too 
severe, the quantity of the syrup must be diminished, or a few drops of 
paregoric may be given with each dose, to prevent the effect upon the 
bowels. The cod-liver oil has rarely failed to be of service, and in 
several instances, it has been the only means that has proved of any avail. 
My formula for administering it is as follows : 

R. — 01. Jecoris Asell., ^ss. 

P. G. Acaciae, ^ss. 

Sacch. Alb., ^i. 

01. Cinnamom., gtt. vi. 

Aquoe Cinnamom., ^iii. — M. 

Give a teaspoonful three times a day. 

It was at one time the custom, and the practice is still advocated by some, 
to resort to calomel in considerable and frequently-repeated, doses, in 
the treatment of impetigo. I have never made use of it in this way, 
disliking its immediate and fearing its remote effects upon the health. 
When, however, the stools have been whitish or clay-colored, and when, 
also, they have been very offensive, I have made use of the remedy in 
small doses, without hesitation, and nearly always with good effect. 

There is a remedy which has been highly recommended by some of 
the German practitioners, and particularly by Jorg, which I shall mention. 
It is the viola tricolor. Jorg (Handbuch der Kinderkrankheiten, p. 516) 
gives it in the form of infusion. The dose is an infusion of from five to 
ten grains of the herb, given morning and evening. The virtues of the quan- 
tity just named may be extracted by from two drachms to half an ounce 
of water. To make the infusion agreeable it may be sweetened. I have 
used this herb myself, prepared in the form of a syrup, in three cases, but 
obtained no good effects whatever from it. 

Purgatives are strongly recommended by some writers in the treatment 
of impetigo. When constipation has been present, and in hearty, vigor- 
ous children, in whom the general health has been too full and sanguine, 
I have made use of cathartics without hesitation, and with much advan- 
tage. But there are many cases of the disease in which remedies of this 
class could not fail to be injurious, as in weakly, delicate children, born 
of tubercular parents, and in those already laboring under diarrhoea, a 
disorder not at all infrequent in severe cases of the disease. When 
laxatives are to be given, the best are castor oil, rhubarb, sulphur, Ko- 
chelle or Epsom's salts in small doses, and occasionally blue pill, calomel, 
or hydrargyrum cum creta, in fractional doses. 

I pass on next to a consideration of the local treatment of severe and 
extensive impetigo, which demands as much judgment, if not more, than 



IMPETIGO. 

the general. The number of local remedies, and combinations of reme- 
dies, recommended in the books for impetigo, is so enormous, that it is 
utterly impossible even to name them all within any reasonable space, 
and I shall refer, therefore, only to those which I have myself made trial 
of and found useful, or which come from such sources as entitle them to 
our attention. Amongst the most important are leeching, emollient 
applications, and certain lotions and ointments. 

In healthy and well-colored subjects, in whom the inflammation accom- 
panying the eruption is considerable, the application ef a few leeches in 
the neighborhood of the eruption is both a reasonable and, as I have 
often found, a most useful practice. In children of from ten to twenty 
months old, I usually apply from two to three American leeches to each 
temple, or behind each ear. If the leeches be very large, one for each 
side of the head will be quite enough. The application ought to be 
repeated in a week or ten days, if it be found to answer well, and even a 
third or fourth repetition may be made if necessary. 

In making use of external applications, whether of emollients, lotions, 
or ointments, in impetigo of the scalp, it is always necessary to prepare 
the head by removing the hair. When the case has already lasted some 
length of time, and has been neglected, so that masses of scabs have been 
allowed to collect and mat the hairs together, it is impossible to remove 
the latter effectually without first getting rid of the incrustations. This 
is best done by means of a thick, moist, and soft poultice, which should 
be enclosed in a fine linen rag, in order to prevent the matter of which 
the poultice may be composed, from adhering to the hairs. Over the 
outside of the poultice should always be placed an oiled silk covering to 
preserve it moist and soft. The poultice may be made of almost any 
unirritating material usually employed for such purposes. One of the 
best is that made of stale bread and water, with the addition of a little 
washed lard, to keep it soft. The water is preferable to milk, as the 
latter often sours soon after being applied. Another excellent poultice 
is one made of ground slippery-elm bark, mixed with a little flaxseed or 
Indian meal, to give it a slightly greater consistence. Each poultice 
may be allowed to remain on the part for three or four hours. 

In some instances, especially after most of the crusts have fallen, it 
will be found equally serviceable, and more convenient, to use emollient 
decoctions instead of poultices. These may consist of decoction of marsh- 
mallow, slippery-elm bark, bran, or flaxseed. They should be applied by 
means of patent lint, or soft Canton flannel, of which several thicknesses 
are to be thoroughly moistened, laid over the diseased part, and then 
covered with oiled silk. These applications may be retained upon the 



TREATMENT. 661 

part for several hours at a time, or day and night for several days, as 
they may be found to suit the eruption. 

After the crusts have been entirely removed, and the inflammatory 
condition diminished, by means of emollients, the latter may be dispensed 
with entirely or during the greater part of the day ; or, they may be 
used only during sleep, at which time they are usually best submitted to 
by the child. At this stage of the disease it becomes proper also to make 
use of different lotions and ointments, intended to modify the action of 
the skin upon which the eruption is seated, or rather which have been 
found useful, by long experience, in promoting the cure of the disease. 

The choice between lotions and ointments must depend very much 
upon trials made in each particular case, since it will be found that some 
are irritated by all — even the mildest ointments, — and bear lotions only, 
while in other instances, exactly the opposite occurs. Amongst the 
lotions, the safest and most soothing that I have employed are weak 
infusions of pipsissewa, American dittany, and the water-cress, which lat- 
ter is often most useful in its effects ; decoctions of bran, marsh-mallow, 
or slippery-elm ; a very weak solution of borax containing morphia ; weak 
lead-water j and a sulphuro-alkaline lotion, composed as follows : 

R. — Potass. Carbonat., gss. 

Sulph. Sublimat., ^i. 

Aqure Fluvial., o v ^* — ^* 

This is to be used on pledgets of lint wetted with it, and applied day and 
night, or, if such constant use prove too irritating, for a few hours only 
every day, or merely by washing the parts frequently with it. M. 
Bouchut (Mai. des Enfants, p. 528) recommends in the highest terms the 
use of Van Swietan's liquor as a lotion. He says he has often seen M. 
Trousseau employ it, and always with success. The formula for its pre- 
paration is as follows : 

R. — Hydrarg. Chlor. Corrosiv., gr. xviii. 

Alcohol, ^iii. 

Aquse Distillat., ^jxxix. — M. 

Liqua. 

This is to be used by washing the head three times a day with rags wet 
with the solution, for a quarter of an hour each time. A sponge must 
not be used, lest it injure by its composition the chemical nature of the 
remedy. Before its use is commenced with the crusts must be removed 
from the eruptive surface, and the hair either cut very closely or the 
scalp shaved. 



662 IMPETIGO. 

During the early stages of severe impetigo, while the disease is still 
attended with acute inflammatory symptoms, only mild ointments ought 
to be employed. Amongst the best of these are cucumber and carrot 
ointment, simple cerate or cold cream, containing some glycerine and 
from four to six grains of camphor, to the ounce, the liniment of lime- 
water and sweet oil, Goulard's cerate, pure or reduced by lard or simple 
cerate, oxide of lead or calamine ointment, or the following ointment, 
somewhat altered from one recommended by Wilson for herpes : 

R. — Glycerinse, gss. 

Liq. Plumb. Subacetat. Dil., ^i. 

Ungt. Flor. Sambuci, gi. — M. 

Fresh and sweet cocoa butter, when it can be obtained, will often be 
found a most soothing application. It is well, as a general rule, to soften 
it a little by rubbing up with it some glycerine or oil of sweet almonds. 

After the inflammation has been diminished by treatment or by time, 
and also in the earlier stages of the disease, it becomes necessary to make 
use of more stimulating ointments than those just named. Of such, some 
of the best are citrine ointment, pure or reduced with lard and glycerine, 
and the following ointment, recommended by Rilliet and Barthez as suc- 
cessful in their hands : 

R. — Vinii Opii, gss. 

Picis Liquid., 7)viss. 

Axungise, ^i. — M. 

Other ointments of this kind are one containing a drachm of calomel 
to an ounce of lard, with or without a few grains of camphor, the crea- 
sote ointment, and ointment of the sulphuret of potassium. 

Dr. Neligan, of Dublin (Dublin Quart. Journ. Med. Science, vol. vi. 
p. 44), who seems to have been very successful in the management of im- 
petigo of the scalp in children, treats it in the following manner. He 
first removes the scabs, when they are abundant, by means of poultices, 
and then cuts close, with a pair of sharp scissors, the hair. He never 
shaves the head, as he has found the operation too irritating. He then 
uses a lotion and ointment containing carbonate of soda. The ointment 
contains from a scruple to half a drachm of the carbonate to the ounce of 
prepared lard, and is lightly smeared over the eruption three times a day, 
and washed off every morning with the lotion, consisting of from half a 
drachm to a drachm of the soda in a pint of rose-water or distilled water. 
The weaker forms of the lotion and ointment are always used when the 
eruption is attended with much inflammation, while their strength is in- 



TREATMENT. 663 

creased as the inflammatory symptoms subside. The head is always 
washed with the lotion, and never with soap and water, as the irritating 
quality of soap tends to retard the cure. In cases where greasy applica- 
tions disagree, and this can be ascertained only by trial, the lotion is 
the only external application made use of, and it is then applied five or 
six times daily. 

In chrouic forms of the disease he states that the application of some 
mild stimulant to the scalp becomes necessary. The one that he has 
found most useful is a very dilute citrine ointment, — from half a drachm 
to a drachm of the officinal ointment, to an ounce of prepared lard. This 
is applied but once daily, at bedtime, and washed off in the morning 
with the alkaline lotion, which latter is used also three or four times dur- 
ing the day. 

In the treatment of inflammatory impetigo he employs an alterative 
medicine, the yellow iodide of mercury, in combination with hydrargy- 
rum cum creta and aromatic powder. At three years old he gives a 
quarter of a grain of the iodide, one grain of the hydrargyrum cum creta, 
and one grain of aromatic powder, twice a week. In infants at the breast, 
he omits the iodide of mercury, and gives either the hydrargyrum cum 
creta or the hydrargyrum cum magnesia, preferring the latter usually, as 
a more certain mild purgative than the former. 

In all cases he keeps " the child strictly on milk diet during the entire 
of the treatment." 



CHAPTER V. 



PAPULES. 



ARTICLE I. 



STROPHULUS. 



This is a form of papular eruption which some writers regard as a 
variety of lichen, giving to it the name of lichen strophulus. It is, how- 
ever, a disease differing somewhat in its characters from the lichen of the 
adult, and as it is peculiar to children, it deserves a separate consideration. 

Strophulus is a disease affecting chiefly infants at the breast, charac- 
terized by a more or less extensive, and sometimes a general eruption of 
papules, which are whiter or redder than the surrounding skin, and are 
accompanied by more or less irritation and itching. 



664 STROPHULUS. 

Its causes are slight disturbances of the digestive apparatus in very- 
young infants, and in older ones the effort of the first dentition. 

Varieties and Symptoms. — The strophulus intertinctus, or red gum, 
consists of an eruption of prominent pimples of a vivid red color, scat- 
tered here and there over different parts or the whole of the body, and 
intermingled with small erythematous patches. The eruption remains 
upon the skin for some time, the papules disappearing and reappearing in 
successive crops, for a week or two, or more, until they terminate by des- 
quamation. It is most common upon the cheeks, backs of the hands, and 
forearms. 

In strophulus confertus, the papules are much smaller, more closely- 
aggregated, much more numerous, and more confluent, than in the first 
variety, and they constitute a more severe eruption. It may be distri- 
buted over the whole surface, but is more commonly limited to a single 
spot, or to several regions, as the face, breast, or arms. The eruption is 
less vivid, but more lasting than that of the strophulus intertinctus, and 
usually reaches its height in twelve or fourteen days, and then subsides. 

In strophulus volaticus, the papules, which are of a vivid color, are dis- 
posed in small, not very numerous, circular groups, scattered over the 
surface of the body, but met with most frequently on the cheeks and 
arms. 

The two remaining varieties, strophulus albidus or white gum, and stro- 
phulus candidus, are both characterized by whitish instead of red papules. 
In the former, the papules are white, minute in size, and surrounded each 
by an areola of a faint red color ; they appear usually on the face, neck, 
and breast, and continue for some length of time. In the latter, the pa- 
pules are much larger, broader, more hard and tense, and are unaccom- 
panied by any redness. They last usually about a week. This eruption 
is most common during dentition. 

Diagnosis. — There is no difficulty is distinguishing strophulus, as it 
is the only papular eruption to which infants are subject. The absence 
of general symptoms and the extreme mildness of the disease are amongst 
its chief characters. 

Prognosis. — The eruption is never attended with any danger. If 
severe symptoms happen to coincide with it, they must depend on some 
other cause than the cutaneous affection. 

Treatment. — As a general rule, strophulus needs no treatment what- 
ever. In infants within the month, the irritation of the skin, if it be 
such as to disturb the comfort of the child, may be allayed by the use of 
the tepid bath, and by dusting with some mild powder, or by anointing 
with cold cream, glycerine and cold cream, simple cerate, or cocoa-butter. 



LICHEN. 665 

If any marked disturbance of the digestive apparatus be present, this 
should be attended to. 

In older children, in whom the disease appears to be associated with 
dentition, the local means spoken of above may be employed, while at 
the same time the gums should be lanced, if necessary, and any gastro- 
intestinal disturbance removed by appropriate treatment. 



ARTICLE II. 



In children the lichenoid eruption takes so constantly the form of 
strophulus, that I deem it unnecessary to give a separate description of 
the former disease, with the exception of one of its varieties, the lichen 
tropicus. No doubt cases of lichen simplex do occasionally occur in 
children as they approach the age of adolescence, but since the disease 
resembles so closely in its characters, and requires the same treatment as 
strophulus, what has been said in regard to that disease will perfectly 
well apply also to lichen. Of lichen agrius, a not uncommon and severe 
form of the eruption in adults, I have never seen an example in a child. 

Lichen Tropicus or Prickly Heat. — This is a form of lichen sim- 
plex which occurs principally in hot climates, and during the hot summer 
season of the more southern temperate climates. It is a very common 
eruption at all ages of childhood, from early infancy upwards, in this 
city, and in most of our Middle and Southern States, and is commonly 
known by the name of prickly heat. 

The chief cause of lichen tropicus is apparently the action upon the 
cutaneous surface of a high temperature, aided, no doubt, by the disturb- 
ances of the digestive function so apt to occur under the influence of that 
condition of the atmosphere. Yery warm clothing, and particularly the 
presence upon the skin of thick rough flannels, is apt to develope the 
eruption. 

Symptoms. — The eruption of prickly heat consists of numerous small 
papulse, few of them being larger than a pin's head, scattered more or 
less thickly over the affected surface. The pimples are of a red color, 
which is more or less bright in tint, according to the extent and intensity 
of the eruption. The skin between the papules retains its natural appear- 
ance when the eruption is but slight or moderate, but when this is copious 



666 PRURIGO. 

and severe, it assumes a faint reddish appearance, owing no doubt to the 
activity of the circulation in the part. 

The eruption is most abundant on the parts covered by the dress, or 
rubbed by the edges of the dress, particularly about the neck, upper part 
of the chest, and on the arms and legs. I have sometimes seen it covering 
the greater part of the body. It is always attended with more or less 
itching, burning, and pricking, which, in older children, cause much fret- 
fulness and scratching, and in those who are younger, restlessness, worrying, 
and more or less disturbance of the sleep. The disorder usually remains 
stationary for several days, and then disappears gradually without desqua- 
mation or other change in the skin ; or, it subsides and increases, or 
disappears and returns, with the rising and falling of the temperature, or 
without any very evident cause, until at last it ceases, not to appear again. 
When the eruption lasts many days, it is almost always accompanied by 
a slight scaly desquamation of the tops of the pimples. 

The diagnosis of this form of eruption is never difficult. Its occurrence 
during hot weather, the character of the papules, their minuteness and 
abundance, and the entire absence of constitutional disturbance, will 
always render it easy of recognition. 

Treatment. — Lichen tropicus is usually regarded as a salutary erup- 
tion, and as not therefore to be interfered with by treatment likely to 
repel it. In fact, it never needs any treatment, except when very 
abundant, and when it annoys the child by the heat and itching it 
occasions. Under these circumstances, the skin should be dusted with 
rye-meal, or anointed two or three times a day with some mild ointment, 
as, for instance, one consisting of glycerine and cold cream or lard ; or, 
the child may be bathed once or twice a day in warm water containing 
bran, slippery-elm, or some other mucilaginous substance. 



ARTICLE III. 



PRURIGO. 



Definition j Frequency. — Prurigo is characterized by an eruption, 
more or less extensive, of isolated papules, which, larger than those of 
strophulus, unattended with any change in the color of the skin, and 
developed usually on the extensor surfaces of the limbs, give rise to the 
most violent and distressing itching, a symptom which constitutes one 
of the most marked features of the disease. 



SYMPTOMS — TREATMENT. 667 

Prurigo is a rare disease in this city amongst the children of the middle 
and upper classes, since I have never met with it. In Europe it is de- 
scribed as occurring in the children of the poor, though it is much less 
common than the eruptive diseases already treated of. Doubtless it 
occurs occasionally in this country also, but I have not found any original 
account of it in the works of American writers. 

Causes. — The only well-ascertained causes of the disease are the un- 
favorable hygienic conditions which exist amongst the destitute classes of 
society, — damp and ill-ventilated dwellings, unwholesome food, especially 
the use of salted meats and fish, and want of cleanliness as to person and 
clothes. 

Symptoms. — The papules of prurigo are small, but slightly prominent, 
and attended with moderate itching, constituting the prurigo mitis ; or 
they are larger, more projecting, and attended with the most violent pru- 
ritus, forming the prurigo formicans. The papules are usually of the 
color of the skin, except when they have been torn by the nails, and are 
generally seated upon the outer surfaces of the limbs, and the upper part 
of the trunk. 

When the itching is severe, the tearing of the papules by the nails 
causes the escape of a small drop of blood from the tops of many of them. 
The blood dries and forms so many small black crusts crowning the sum- 
mits of the papules, a peculiarity which constitutes one of the most dis- 
tinctive features of the disease. The papules terminate by absorption or 
by a slight desquamation. 

The duration of the eruption is very uncertain. In acute cases, when 
properly treated, it may end in a few weeks, though it often, and indeed 
more generally, lasts for several months. 

Diagnosis. — The only diseases with which prurigo is likely to be con- 
founded are strophulus or lichen. It may be distinguished, however, 
generally with ease, by the facts that the papules of prurigo are larger, 
less numerous, and more extended, than those of strophulus or lichen ; 
that in the latter diseases the papules are never crowned by the small 
black crusts of prurigo, and they are never attended with the same vio- 
lent itching as the former. 

Prognosis. — Prurigo is never perhaps a dangerous disease, though 
usually a very troublesome one, from the severe irritation which attends 
it, from its not unfrequently obstinate resistance to treatment, and its 
disposition to relapse. 

Treatment. — The internal treatment of prurigo in children should 
consist in the use of sulphur, given alone or in combination with magne- 
sia, of demulcent drinks, of mild laxatives when there is constipation, 
and of such remedies as may be rendered necessary by any disordered 



SQUAMAE. 

state of the digestive function. The diet must be carefully regulated. 
It ought to be nourishing and sustaining, but at the same time light and 
of easy digestion. 

In addition to the internal treatment, simple warm -water baths, or 
emollient baths of flaxseed, bran, slippery-elm, or marsh-mallow, should 
be made use of in the early stage of the disorder. At a later period, 
alkaline baths, containing from three to eight ounces of carbonate of pot- 
ash to each bath, according to the age, are recommended by Cazenave and 
Schedel. To allay the cutaneous irritation mild ointments are often found 
useful. Billard employed with success, in a child six months old, inunc- 
tions with the oil of sweet almonds. When the case is obstinate, — resist- 
ing emollient and alkaline baths, sulphurous baths must be made use of. 



CHAPTER VI. 

SQUAMA. 

The four species of scaly diseases, lepra, psoriasis, pityriasis, and 
ichthyosis, are so much more rare in children, and therefore so much less 
important practically, than the various eruptions we have thus far consi- 
dered, that I deem it unnecessary, in a work limited in extent like this, to 
attempt a detailed account of them. I shall make merely a few observa- 
tions on each, referring the reader, should he desire further information, 
to the work of Cazenave and Schedel, or to that of Wilson. 

Lepra is said by Billard, Baron, and Bayer, never to occur in children 
at the breast, though it occurs not very rarely after the first dentition. 
It cannot be by any means frequent, however, at any age of childhood, 
since I have never met with an instance of it. 

Psoriasis is a more common disease in children than lepra, so much so 
indeed, that Willan describes a variety of it under the title of psoriasis 
infantilis. The only case that I ever met with was a very mild one in a 
child nine years old. It is met with in two forms, the psoriasis diffusa 
and guttata, of which the former is said to be the more frequent. 

Psoriasis diffusa appears in the form of patches of rather large, but 
very variable size, of irregular shape, and covered with thin scales of 
dried epidermis, which are constantly falling off and being renewed. 
When the scales are removed the surface of the eruptive patch is seen to 
be of a dull red color, somewhat rough, and raised above the surrounding 
skin. In severe cases, as the disease occasionally occurs in young chil- 



PSORIASIS — PITYRIASIS — ICHTHYOSIS. 669 

dren, the skin presents numerous chaps and fissures, and is often excori- 
ated more or less by the dress, or by the neighboring surfaces. From the 
excoriations is sometimes poured out an unhealthy secretion, which har- 
dens and forms scabs. 

Psoriasis guttata appears in small, reddish, and rounded elevations, more 
elevated at the centre than circumference, and of different sizes ; — from 
that of the head of a pin, as mentioned by Billard, to that of a large pea, 
as seen by myself, and which become covered very soon after their ap- 
pearance with fine, minute, and whitish scales. 

A third variety, psoriasis inveterata, a severe, obstinate, and inveterate 
disease, as met with in adults, is very rare, if not unknown, in children. 

Treatment. — In recent cases psoriasis is to be treated with simple 
warm water or emollient baths, and with mild liniments or ointments, 
such as oil of sweet almonds, glycerine alone, or glycerine mixed with 
cold cream or simple cerate. In more chronic cases the condition of the 
skin must be modified by means of weak alkaline or sulphurous lotions or 
baths, and by ointments whose action upon the skin is of the same kind. 
M. Berton recommends highly tar ointment containing one part of tar to 
four of lard, which he states has been used very successfully by M. Emery. 

In all cases the digestive function must be carefully attended to, any 
disorder that it may present being removed as rapidly and effectually 
as possible by the proper remedies. 

The active alterant substances, so much used in the psoriasis of adults, 
and particularly arsenic and cantharides, ought not to be employed for 
children if they can in any way be avoided, and if employed, they should 
be given in very small doses. 

Pityriasis is a slight scaly disease which may attack the head only or 
extend to other parts of the body. In children, however, it is generally 
confined to the scalp, and may be recognised by the existence on that part 
of innumerable small, thin, whitish, furfuraceous scales, which form a 
thin or thicker covering for the scalp, in proportion to the amount of care 
bestowed on the cleansing of the head. The scales of epidermis are easily 
rubbed off, and the surface beneath is rarely found to present even the 
slightest inflammation. 

It is a disorder of minor importance, and seldom requires other treat- 
ment than some mild lotion or ointment, and strict cleanliness. 

Ichthyosis is an eruptive disease in which there appears on various 
parts, and usually over the larger portion, of the skin, epidermic patches 
or squamae, that are hard and dry, and of more or less considerable size. 
The patches are generally of a dirty gray or earthy color ; they exfoliate, 
and leave the skin beneath a little thickened and roughened, but never 
inflamed. The disease is unattended with either heat, pain, or itching. 



670 FAVUS. 

It is ordinarily congenital, lasts many years, and, according to Cazenave 
and Schedel, is incurable. 

Billard recommends, however, in the ichthyosis of new-born children, 
the use of warm and emollient baths, frictions with oil of sweet almonds 
or olive oil, acidulated drinks, and perfect cleanliness. 



CHAPTER VII. 



DISEASES OF THE SKIN NOT CLASSIFIED AMONGST THE PRECEDING. 



ARTICLE I. 



Favus is a peculiar disease of the scalp, long confounded by different 
writers with other and very dissimilar affections of that part. In conse- 
quence of this confusion it has received a great variety of names, of which 
the most generally known are porrigo and tinea. In adopting the above 
title I follow the example of Erasmus Wilson, amongst the English, and 
of Rilliet and Barthez, G-ibert, and Rayer, amongst the French. 
' Definition; Synonymes; Varieties; Frequency. — Favus is a 
specific contagious eruption of the scalp, depending upon inflammation of 
the hair-follicles. It is characterized at first by small yellow pustules, 
countersunk in the skin ; these are soon converted into yellow cup-like 
crusts, which adhere often for a very long period. It usually causes per- 
manent loss of hair at the affected part. 

The disease is described by most of the English writers under the title 
of porrigo, but as several other eruptions have been included under the 
same name, I think it best to follow the example of Mr. E. Wilson, and 
call it Favus. By Biett and Cazenave it is designated, after Willan, 
porrigo favosa and porrigo scutulata. Rayer and Gibert, as above men- 
tioned, give it the name of favus. 

There are two varieties of favus, the favus dispersus, the porrigo favosa 
of most writers, and the favus confertus, the porrigo scutulata of many 
observers. 

The disease is much less frequent than impetigo and eczema of the 
scalp, but is nevertheless constantly met with amongst the crowded popu- 
lations of Europe. In Paris I saw it on several different occasions. In 
this country it is more rare, and amongst the middle and upper classes, 



CAUSES — SYMPTOMS. 671 

at least of this city, is almost unknown, since I have never met with a 
case of it in my own practice. 

Causes. — The only well-ascertained exciting cause of favus is conta- 
gion, a quality of the disease now acknowledged by all. It may be propa- 
gated by direct contact of the diseased with a healthy skin, or by means 
of combs, brushes, or other articles of the toilet. It has been twice pro- 
pagated by direct inoculation, — once by Remak, and once by Bennett. 

It occurs at all seasons, attacks either sex indifferently, and is met 
with at all ages, but is especially frequent in children and young people. 
Certain conditions act as predisposing causes in its production, and may 
alone, perhaps, give rise to its development. These conditions are un- 
healthy hygienic influences, as unwholesome and insufficient food, poverty, 
filth, and the living in low, damp, and ill-ventilated dwellings. It is met 
with most frequently in persons of feeble, lymphatic, and especially in 
those of scrofulous constitution, though, be it remarked, it occurs also in 
persons of strong and vigorous health. 

Symptoms. — Favus dispersus, or Porrigo favosa. This variety 
begins with very small pustules of a peculiar straw-yellow color, which 
exhibit from the first the special character of not being raised at all above 
the level of the skin. Directly after their formation, the yellowish matter 
which they contain begins to concrete, and there can be perceived from 
this early period a central depression in the crusts, which becomes more 
marked as these augment in size, so that at the end of five or six days it- 
is perfectly evident. Each pustule, and of course each crust is, as a 
general rule, traversed by a hair. The favous crust is a very remarkable 
feature of the disease, and is in itself a pathognomonic symptom. As it 
increases in size, which it does gradually until it reaches in some in- 
stances a diameter of half an inch, the central depression above spoken 
of becomes more and more distinct, and the crust assumes, from this cir- 
cumstance, the shape of a cup with an inverted edge. This cup-like 
form, the peculiar straw-yellow color, and the fact that each crust is usu- 
ally pierced by a hair, are the distinguishing characters of the disease. 

The pustules are usually isolated at first, though they may be arranged 
in groups of irregular size. When numerous, the crusts, by their gradual 
enlargement, touch at their edges, and blend into larger or smaller patches 
of irregular shape, but still presenting many little depressions correspond- 
ing to the first- formed pustules. In rare cases, the disease is so extensive 
as to form a kind of mask covering the whole scalp. 

When the disease is not interfered with by treatment, the crusts remain 
adherent for a long time, — for months or even years ; they become also 
paler in color than they were at first, and so dry and pulverulent, as to 
break very readily when rubbed or touched. They become, moreover, 



672 favus. 

thicker and more massive, and lose their first regular cup-like form, from 
the disappearance of their depressions, and from the irregular and uneven 
shape given to their edges and surfaces, by the breaking which they under- 
go. When the case runs on in this way, the head exhales a most unplea- 
sant odor, which has been compared to that of the urine of a cat. In 
some instances, where the disease is grossly neglected amongst the very 
poor, pediculi form in abundance amidst the crusts, and add to the dis- 
gusting appearance of the disorder. 

When the crusts have been removed by any means, the surface of the 
scalp is seen to be red, moist, and to present slight erosions or even ulce- 
rations. The crusts are re-formed only by the eruption of new pustules. 

An invariable and unfortunate sequel to the favous disease is a more 
or less extensive loss of the hair. The hairs become loose from a very 
early period of the disease, and can be pulled out with great ease. 
As the case goes on they fall out, and the scalp is left smooth, shining, 
uneven, and deprived of hair. On these spots the hair seldom grows 
again, and if it does, it comes out thin, woolly, and with every appearance 
of weakness and unhealthfulness. 

Though the usual and favorite seat of favus is the scalp, it is met with 
occasionally on the forehead, temples, chin, and eyebrows, and, in still 
rarer instances, on the shoulders, elbows, forearms, on the upper and 
outer parts of the legs and thighs, and on the scrotum. Even in such 
cases, however, it has generally existed first on the scalp, and extended 
thence to the other parts, though it may sometimes begin upon the 
trunk or limbs in consequence of a direct application to them of the con- 
tagious element. 

Favus Confertus or Porrigo Scutulata. — In this variety of favus 
the pustules are arranged so as to form circles or rings upon the forehead 
or scalp, instead of being dispersed irregularly over the scalp, as in the 
preceding variety. The disease begins with red, circular patches, attended 
with a good deal of itching, upon which, after a short time, appear small 
yellow pustules, that seem to be sunken in the skin. The pustules are 
more numerous on the circumference than at the centre of the red patch 
or disk ; or the latter increases in size by the extension of the disease to 
the follicles just beyond its outer edge. The pustules are exactly like 
those of favus dispersus, except that their yellow color is of a lighter 
tint. They desiccate very rapidly, and form crusts which are very thin 
at first, never very thick, and of an irregular shape. 

When the disks are very numerous, either originally, or by propaga- 
tion of the disease from part to part, they meet at their borders, blend 
together, and give to the scalp the appearance of an extensive and irre- 
gular crust, presenting at its circumference curved lines, marking the 



SYMPTOMS — NATURE. 673 

segments of circles of which the whole is composed. The crust has 
sometimes covered the whole scalp, excepting merely a small border at 
its circumference, where may still exist some scanty remains of the hair. 

When the crusts are removed the surface beneath is found to be red 
and tumid, according to Wilson, and to present numerous yellow points. 
Cazenave and Schedel state that when the crusts fall, they leave exposed 
a large, uneven, furfuraceous patch, upon which new favous pustules do 
not appear for a long time often. The hair is in great measure destroyed 
over the diseased surfaces, though not so completely, it is said, as in the 
other variety. 

Favus is not, in either variety, attended with constitutional symptoms. 
The only marked local symptom complained of is the itching, which is 
always greatly aggravated by want of cleanliness. 

Nature of Favus. — There has been and there is still much difference 
of opinion amongst observers as to the nature of favus, some supposing it 
to be a disease of the sebaceous glands of the scalp, some of the hair 
follicles, while others, particularly some of the most recent observers, 
assert that it is an organic growth, — a vegetable fungus or parasitic plant. 
The latter opinion, first put forth by Reinak, has been strongly maintained 
since by Schoenlein, Gruby, Hughes Bennett, Lebert, Yogel, Robin, C. 
Neligan, and others, whilst it is opposed by Cazenave, Wilson, and a few 
others. To attempt an accurate description of the microscopic appear- 
ances of the supposed parasitic plant, or to notice the arguments for and 
against its existence, would require more space than I can devote to it, 
and I must therefore refer the reader to the work of M. Lebert (Physio- 
logic Pathologique, tome ii., p. 477), or to that of Mr. E. Wilson, on 
Diseases of the Skin. I will merely state that the arguments brought 
forward in support of the opinion as to the cryptogamic nature of the 
disease are to me very convincing. The following imperfect sketch of 
the microscopic appearances of the supposed plant, will suffice to give 
some idea of its nature to those who have not time nor opportunity for a 
more thorough study of the subject. It is taken from 31. Lebert' s work. 

M. Lebert states that the favus itself is a substance entirely foreign to 
the skin, and that it has no resemblance to the favous pustule, with which 
it has been until lately confounded. The favus above alluded to is the pecu- 
liar yellow, dry, smooth, brittle, and cupped crust, mentioned in the de- 
scription of the symptoms of the disease. The surface of this body is com- 
posed of an envelopment-membrane of a sulphur-yellow color, in which 
the microscope shows a homogeneous and finely punctuated substance. 
The interior, of a pale white color, is porous, and formed of grumous 
particles consisting of sporules, and of simple or ramifying branches. The 
sporules, which occupy much the larger part of the interior of the recep- 

43 



674 favus. 

tacles, are of a rounded or more frequently of an oval form, and have 
well-marked edges, and a homogeneous and slightly opalescent interior. 
The diameter of the most recent is T §^ths of a millimetre. Many of these 
sporules are seen to be grouped together, while some are more elongated, 
and present a contraction in the middle ; others are nearly triangular in 
form, with rounded angles; others, yet more elongated, are marked with 
several contortions ; while some again are composed of confluent sporules 
that have ended by forming branches, the intersected walls of which show 
the primitive separation of the globules. These branches may exhibit at 
a later period ramifications, which resemble sometimes in their arrange- 
ment the conjugated branches of lygnsema; other branches, ramified or 
simple, contain minute granules; in addition to the branches of y§o^ ns °f 
a millimetre in diameter, some very delicate ones of scarcely T § J^ths are 
seen. Amongst the branches and sporules may be perceived a conside- 
rable number of molecular granules of the diameter of from T Jo^ n *° 
yl^ths of a millimetre, which are probably imperfectly developed spo- 
rules. Some sporules, completely formed, seem to have a double enve- 
lopment-membrane, and others present in their interior something like a 
nucleus. 

Diagnosis. — The diagnosis of favus rarely presents any difficulties. 
The peculiar pustules which exist at first, — small, yellow, on a level with 
or below the surface of the scalp, and the crusts which so soon follow 
these, saffron-yellow in color, dry, and cup-shaped, will mark a case of 
favus dispersus from every other disease. In favus confertus the same 
characters exist, but the crusts and pustules are arranged on circular 
erythematous disks, instead of being isolated or dispersed as in favus 
dispersus. 

From impetigo of the scalp, which is the only disease with which it is 
at all probable that it would be confounded, it may readily be distinguished 
by an examination of the primary characters of the two disorders. This 
primary character can always be found by searching at the outer edges of 
the diseased surface. In favus the pustule is small, depressed, and con- 
tains very little fluid, while in impetigo it is large, globular, and projecting. 
The crusts are very different : — in the former dry, as though dusted with 
sulphur, cup-shaped, depressed, and usually traversed by a hair; in the 
latter, rugous, irregular in shape, not cupped, resting above the skin, and 
generally somewhat moist and soft. Lastly, the alopecia which so con- 
stantly results from favus, does not occur in impetigo. 

Prognosis. — Favus is a serious disease because of its usually long 
duration, the difficulty often experienced in effecting its cure, and because 
of the loss of hair which it occasions. 

Treatment. — The treatment of favus should be both general and 



TREATMENT. ' 675 

local, for though some writers, and particularly Cazenave and Schedel, 
state that it must be altogether external, and that, in spite of numerous 
trials, they do not feel authorized to propose any internal means (Malad. 
de la Peau, 4eme ed., p. 326) ; others, as Wilson, Bennett, and Neligan, 
recommend constitutional remedies as of very great importance in assist- 
ing the cure. 

The general treatment must be such as may seem called for by the 
state of health of the individual patient. When, as so often happens, 
the disease occurs in a scrofulous person, cod-liver oil, iodide of potas- 
sium, nourishing food, air, and exercise, are of the utmost importance. 
When the health of the patient is feeble and broken from the want of 
wholesome and abundant food, from insufficient clothing, or from residence 
in a vitiated, close, and confined air, the removal of these conditions, 
which undoubtedly act as predisposing causes in the production of the 
disease, cannot but aid in its cure. Dr. Neligan (Dublin Quart. Journ. 
of Med. Sci.j vol. vi. p. 56) recommends very highly the use of the 
iodide of arsenic as a constitutional remedy. He states that it may be 
given with the greatest safety to the youngest child, "its effects being, 
of course, duly watched." The dose for a child six years old is one- 
fifteenth of a grain, and for a younger one, from one-eighteenth to one- 
twentieth of a grain, three times a day. Dr. Neligan speaks, however, 
{Loc. cit. p. 62) of substituting the yellow iodide of mercury for the 
iodide of arsenic in the case of a child three years and a half old, being 
afraid to give the latter to so young a child. He nevertheless gave this 
remedy afterwards in the case referred to, but in the dose only of the 
twenty-fourth of a grain every morning. It is given to children in the 
state of powder mixed with sugar or aromatic powder, and produces, when 
the system is saturated with it, some constitutional symptoms, as acute 
headache, dryness of the throat, etc. He has given it, however, in some 
cases, in full doses for several weeks without any manifestation of its 
effects, further than those produced upon the disease. When it does 
give rise to constitutional symptoms its use is to be intermitted for some 
days, and an active purgative administered. 

The local treatment of favus is undoubtedly that upon which we mast 
chiefly rely, since without it it is questionable whether the disease ever 
gets well. Moreover, all writers and persons of much experience agree 
in the high estimate they make of the importance of this part of the 
treatment. 

The first and most essential step in the local treatment is to insist upon 
thorough cleanliness of the diseased part. The hair should be cut short 
or shaved off. As shaving the hair is difficult and often painful, cutting 
it short with sharp scissors is generally preferable. The crusts must then 



676 favus. 

be removed. Some recommend for this purpose poultices, but these are 
condemned by Wilson, as clumsy, and by Lebert as causing the extension 
of the disease by the softened sporules which spread to the surrounding 
surfaces and propagate the disorder. Wilson recommends their removal 
by means of a local vapor-bath, applied through the medium of a caout- 
chouc cap, or, if this is not at hand, by laying a piece of folded lint, 
wetted in a solution of sub-carbonate of soda or potash, upon the head, 
and covering it with an oiled silk or gum elastic cap, which should in- 
clude the entire scalp. M. Lebert insists upon the necessity of removing 
the favi (not the pustular crusts which accompany the specific vegetable 
growth), in their dry state, by means of small spatulas, needles, or some 
kind of instrument. The epidermis is readily detached from around the 
favus, and this latter, which adheres but slightly to the skin, is then 
easily removed. M. Lebert states that this is so easily done, that he has 
been able to teach his ward-attendants to remove them without pain to 
the patients. 

After the crusts have been gotten rid of, the scalp should be well 
washed morning and evening, with soap and water, in order to remove 
any favous sporules that may have escaped, and then carefully combed, to 
remove any hairs loosened by the disease, as these have been found to act 
as irritants to the diseased scalp. The cleansing of the scalp with soap 
and water daily, and the subsequent removal of the loosened hairs, ought 
to be continued throughout the whole duration of the disease. Attention 
to these points is said, by all writers, to be of the utmost importance, and 
to go very far towards curing the disease. But not only do they act 
beneficially in themselves ; — they procure also a clean and uncovered sur- 
face, to which the local remedies that may be necessary can be applied 
directly and with the greater effectiveness. 

As soon as a clean surface has been obtained, some application intended 
to destroy the vitality of the vegetable growth, ought to be made use of. 
One of the best for this purpose is a solution of corrosive sublimate, the 
strength of which, according to Lebert, ought to be, when employed in 
lotion, from two to four grains to the ounce, and when used as a fomen- 
tation, weaker. Dr. Bennett (Ranking' s Half-Yearly Abstract, No. xii. 
1850, Am. ed., p. 73), employs, to fulfil this indication, cod-liver oil. 
The head is kept constantly smeared with the oil, and covered with an 
oiled silk cap. 

There are various other remedies that have been applied to the diseased 
scalp empirically, either to "modify the state of the skin," to "excite 
the disordered follicles to healthy action," or, lastly, to " destroy the 
vitality of the fungus, and, by altering the nature of the soil on which it 
flourished, to prevent its reproduction." Without attempting to define 



TREATMENT. 677 

the mode in which any of these various substances may produce their 
effect, I deem it best to mention as succinctly as possible those which 
have the strongest testimony in their favor. 

Mr. E. Wilson states that the medicine he has found most valuable in 
favuSj is iodine, either in the form of vapor, and used twice in the day, 
or tincture of iodine brushed upon the scalp three times a day, in the 
morning and evening after each ablution. "In the majority of ca c es," 
he says, "I have succeeded in curing the disease by this plan." Next to 
iodine, he prefers a spirituous solution of bichloride of mercury, pen- 
cilled on the patches. With this fluid he has frequently succeeded in 
checking the disease at once. 

Dr. Bennett's application of cod-liver oil, has been referred to above. 
This, in connexion with the constitutional treatment for scrofula, is said 
to have cured, on an average, in six weeks. 

MM. Cazenave and Schedel recommend alkaline and sulphurous ap- 
plications, and acidulated lotions. They speak very favorably of, and 
give much the highest place, amongst the substances to be used in fric- 
tion, to the iodide of sulphur. This remedy was originally made use of by 
Biett, and employed by him with much success. Its efficacy is attested 
to also, by Lebert. It is used in the form of an ointment consisting of 
from a scruple to half a drachm of the drug to an ounce of lard, and is 
to be applied morning and evening to the diseased surfaces by gentle fric- 
tion. 

Dr. Neligan (Loc. cit.) puts the patient upon the constitutional treat- 
ment before described, and makes use of the following local treatment. 
The hair is cut, not shaved, and a linseed-meal poultice applied and kept 
on for twelve hours, so as to soften the crusts. As soon as the poultice 
is removed, the head is well washed with a carbonate of potash lotion 
(3i to Oj. of distilled water), and slightly brushed with a soft hair-brush 
or roll of lint ; the scalp is then covered with the carbonate of potash 
ointment (grs. xx. to 3ss. to lard ^i) spread on lint, and over it a closely 
fitting oil-silk cap is placed; the ointment is renewed twice daily. By 
these means the crusts are generally removed in two or three days. At 
the end of this time, the carbonate of potash ointment is replaced by one 
containing the iodide of lead (3ss. to lard gi); the head is still to be 
washed with the carbonate of potash lotion. When the iodide of lead 
causes inflammation of the scalp, as sometimes happens after the first few 
days, it should be intermitted for a day or two, and the lotion employed 
alone three or four times daily. After this first attack of inflammation 
disappears, Dr. Neligan has not seen it recur again, although the use of 
the ointment has been persisted in for months. The strength of the oint- 
ment is to be increased after a fortnight, if the disease appear again, even 



678 RINGWORM OF THE SCALP. 






to double that mentioned above. After continuing this treatment for at 
least three weeks or a month, all external applications should be stopped, 
and the hair allowed to grow, so as to ascertain if the fungus will be re- 
produced. Should it appear again, the local applications must be had 
recourse to as before. The iodide of arsenic is to be continued until we 
are quite satisfied that the cure is complete. During the whole of this 
treatment, the patient is to be kept on a milk diet. 



ARTICLE II. 

TRICHOSIS FURFURACEA OR RINGWORM OF THE SCALP. 

Definition; Synonymes; Frequency. — Ringworm of the scalp is 
a disease about which much discussion has been had lately. It begins 
with more or less numerous patches of a circular or oval shape, which, 
after having presented for a short time, according to some, minute vesi- 
cles, become the seat of a fine furfuraceous desquamation. The disease 
always affects the growth of the hair, giving to the latter a sickly appear- 
ance, and causing a temporary alopecia. It is contagious. 

This disease is known also by the names of porrigo furfuracea, and 
porrigo scutulata, having been confounded by some writers, under the 
latter title, with true porrigo scutulata or favus dispersus. By Cazenave 
it has been called herpes tonsurans ; by Neligan it is called herpes capi- 
tis ; and by Wilson, trichosis furfuracea. 

It is a frequent disease in England, but a rare one in France ; it is not 
uncommon in this city, as I have met with thirteen cases of it. 

Causes. — This disease appears to be propagated chiefly by contagion, 
— at least this is the only clearly ascertained cause that has been disco- 
vered. Its contagious character is positively asserted by Cazenave and by 
Neligan, and in the thirteen cases that came under my observation, I 
could have no doubt of its being extended in this manner, since they all 
occurred in five families, three cases in each of three of the families, and 
two in each of the remaining two. Moreover, in all of the families, the 
disease appeared first in one child and extended afterwards to the 
others. 

Mr. Wilson believes the cause of the disease to be imperfect nutrition, 
" which careful examination will never fail to detect." In not one of 
the thirteen cases that I have seen, had I the least reason to suppose 
that imperfect nutrition was the cause of the eruption, since they all 
occurred, as it chanced, in families living in easy or very affluent circum- 
stances, the children of which were perfectly well lodged, well clothed, 



SYMPTOMS. 679 

and well fed, and to whom every attention required by the nicest clean- 
liness was given. 

The disease is confined to childhood and early youth, and is most 
common between the ages of three and twelve years. 

Symptoms. — Those who regard this disease as a variety of herpes, 
describe as its first symptom the appearance on the scalp of a " small 
ring of minute vesicles, not more than an eighth of an inch in diameter, 
without any redness or other mark of inflammation beyond a slight ting- 
ling, — not itching. These vesicles are attended with scarcely any dis- 
charge, they soon drying up and desquamating; but, as they dry at 
the centre they spread upon the circumference, and the diseased spots, in 
the course of a few days, attain the size of a shilling. (Neligan, Loc. cit., 
p. 33.) Mr. Wilson, on the contrary, who regards it as a disease of the 
hairs, makes no mention of vesicles, but describes as the leading character 
of the disease the formation of a thin layer of scurf, either in separate 
scales around single hairs, or in patches which include several or a con- 
siderable number of hairs. In the early stage, he says, nothing more is 
perceptible than these scales, but the diagnosis is made evident by the 
observation that the scurfiness is limited to particular hairs, and clusters 
of hairs, and that the patches corresponding with these clusters have a 
circular or oval form. In this early stage also, the aperture of the follicle 
of the diseased hair is generally more or less prominent or papillated, 
having the appearance of being drawn up by the growth of the hair, and 
resembling what is called goose-flesh, or cutis anserina. If, at this time, 
one of the hairs issuing from a furfuraceous patch, be gently pulled, it 
will probably break off near the skin or within the follicle, instead of 
coming up by the root as in health. 

Whether the disease be vesicular or not in the early stage, it is gene- 
rally acknowledged to become, very soon after its appearance, furfuraceous. 
For my own part, I have never been able, though I examined the cases 
that came under my notice with the minutest attention, to detect even a 
single vesicle, and I am strongly inclined, for this and other reasons, to 
believe that the disease is not a herpes, but as Mr. Wilson supposes, an 
affection of the hairs. 

When once established, the disease appears in the form of furfuraceous 
patches usually of a circular shape, which are, at first, not more than an 
eighth or a quarter of an inch in size, but which increase gradually until 
they attain a diameter of one or two inches, and seldom more. The dis- 
eased surface is slightly thickened, elevated, and covered with fine, dry 
scales, which are very easily rubbed off, and which are quickly renewed 
after being removed by any cause. The only local symptoms noticed by 
the patient is itching, and this is not often very troublesome. 



680 RINGWORM OF THE SCALP. 

At this time, also, the hairs present an appearance which is very cha- 
racteristic. In the very early stage they are bent on themselves and 
twisted, so as not to lie smooth, and the roots are somewhat matted 
together by the furfuraceous scales of the disease. A little later they 
break off at a short distance from the diseased surface, leaving the circular 
patches partially deprived of hair. The broken hairs are uneven in 
length, and otherwise altered in appearance, being bent and twisted, and 
having become lighter in color than the original hairs, so as to assume 
somewhat the look of bundles of tow. 

In ringworm of the scalp it happens occasionally that patches like 
those upon the head, are found upon the neck and arms, and even on 
other parts of the body. The patches forming upon the body present 
scales more minute than those seated on the scalp. The diseased patches 
increase from the circumference, while the centre returns to its natural 
state. 

Nature of the Disease. — Some writers regard this disease, as has 
already been stated, as one of the varieties of herpes, while others deny 
its vesicular nature, and conclude it to be an affection of the hairs. It 
appears to me, however, that the circumstances of its being contagious, 
the difficulty of its cure, its chronic character, and the very short dura- 
tion, and even, according to some, the doubtful existence, of vesicles in 
the disease, make very strongly against the opinion of its herpetic nature. 
I am, therefore, much more disposed to adopt the idea of its being a pecu- 
liar and specific affection of the hairs themselves, but whether it be, as 
Wilson supposes, the result of some diseased condition of the nutrition of 
the hair, or whether it consist, as Gruby has advanced, in the production 
of a parasitic mucedinous growth, has not yet been clearly ascertained. 

Diagnosis. — This disease is easily distinguished from other eruptions 
of the scalp. The appearances it presents are utterly unlike those of 
favus, impetigo, or eczema. In the first of these, the peculiar cup-shaped 
crusts; in the second, the projecting yellow pustules or thick masses of 
yellow soft scabs; and in the third, the numerous minute vesicles scattered 
irregularly over the scalp, and followed by thin brownish-yellow scabs, 
or fine furfuraceous scales, through which there weeps a small amount of 
secretion, are entirely unlike the eruption of ringworm, which consists of 
more or less regularly circular patches, dry, mealy, and papillated, and 
producing at length a broken and tow-like condition of the hairs, and 
partial baldness. 

Prognosis. — Ringworm of the scalp is entirely devoid of danger, but 
it is an exceedingly troublesome disease for the patient, as it is apt to 
spread to other children, and as it is often very difficult of cure. 

Treatment. — The cases of ringworm of the scalp that have come 



TREATMENT. 681 

under my charge, have proved in most instances very rebellious to treat- 
ment. The remedies that have proved most useful are a sulphuro-alka- 
line lotion, composed of one drachm of sub-carbonate of potash and two 
of sulphur, to a pint of water, applied by washing with a sponge several 
times a day, and an ointment consisting of a drachm of muriate of am- 
monia mixed in an ounce of sulphur ointment, applied first at night by 
inunction, and after a time on rags. 

When, in connexion with this disease, the general health of the patient 
is in any degree debilitated and injured, remedies of a tonic and strength- 
ening kind ought to be prescribed. The best of these are iodide of iron 
in syrup of sarsaparilla, the citrate of iron and quinine, or cod-liver oil. 

Mr. Wilson commences the treatment by the application of some mode- 
rately powerful stimulant, such as the acetum cantharidis, or the stronger 
acetic acid, which he applies once to the diseased spots. After the ten- 
derness produced by this application has abated, he anoints the patches 
daily with some moderately stimulating ointment, such as the citrine 
ointment diluted with ceratum cetacei. Another ointment which he 
strongly recommends, is one composed of a drachm of sulphate of zinc to 
an ounce of simple cerate. During the treatment the head is to be 
washed once a day with soap, and when dry, anointed with pomatum. 
Mr. Wilson regards the keeping the scalp constantly moistened with 
some oleaginous matter as an important adjuvant to the cure. 

M. Cazenave, unlike Wilson, condemns the use of irritating applica- 
tions as injurious. The most successful treatment he has employed is the 
following. He rubs into the scalp every evening an ointment composed 
thus : 

R. — Acid. Tannici., 9i. 

Axungioe, 3!. 

Aquse, q. s.— M. 

In the morning the scalp is washed with one of the following lotions : 

R.— Potass. Carbonat, ^ss. vel 9ii. 

Aquae, Oj. 

Liqua. 



Or, 



R.— Sodae Borat., E ss - vel d i[ - 

Aquse, Oj. 

Liqua. 



Two or three times a week he prescribes an alkaline bath, advising the 
patient to wash the head with the water of the bath. 

Dr. Neligan, of Dublin, treats this affection in the same mode as impe- 



682 RINGWORM OP THE SCALP. 



tigo of the scalp. The reader will find an account of his method in th 
article on impetigo. (See page 662). 

Before concluding my remarks upon this disease I wish to state that 
my own experience in its treatment has taught me that it is one of the 
most obstinate disorders to which children are subject. I once made a 
faithful trial of Dr. Neligan's treatment in three cases occurring in one 
family, and though the disease was ameliorated, it was not cured. The 
cases passed out of my hands after several months, and I never heard 
what became of them. In another case that came under my notice, acetic 
acid and many different stimulating ointments had been tried for a period 
of two years without any lasting good effect. I prescribed the muriate 
of ammonia and sulphur ointment, but it failed. The disorder has slowly 
disappeared, since then, under the persevering employment of tar oint- 
ment, and vegetable diet. 



: 



CLASS VI. 
WORMS IN THE ALIMENTARY CANAL. 

GENERAL REMARKS. 

There are five different species of worms found in the alimentary canal. 
They are the Ascaris lumbricoides, or round worm ; Ascaris verniicularis, 
thread-worm, seat-worm, or, as it is popularly called, ascarides ; Tricoce- 
phalus dispar, or long thread-worm ; Taenia solium, common tape-worm, 
or long tape-worm ; and the Bothriocephalus latus, taenia lata, or broad 
tape-worm. 

I shall not attempt to discuss the question of the mode of origin of 
human entozoa, about which much difference of opinion still prevails, 
some asserting that their ova or germs are introduced from the exterior, 
while others, embarrassed by the difficulty of accounting for their exist- 
ence in organs enclosed in shut cavities, advocate the opinion that they 
are the result of a spontaneous generation. 

I shall give a short description of each of the intestinal entozoa, in order 
that they may be readily distinguished, but will treat of the causes, symp- 
toms, and treatment only of the first two, inasmuch as the tsenias very 
rarely exist during infancy or childhood, and the tricocephalus is much 
less frequent than the round and seat-worms, and gives rise to symptoms 
of the same kind as the former. 

Description. — The Ascaris lumbricoides, or, as it is commonly called, 
lumbricoides, lumbricus, or round-worm, is shaped not unlike the com- 
mon earth-worm, having a cylindrical body, which is attenuated towards 
either extremity, but particularly the anterior. It varies in length gene- 
rally between six and twelve inches, and is usually about two or three 
lines in thickness. The young worm, about an inch and a half long, is 
rarely met with. The head of the animal is at the smallest extremity, 
and may be distinguished by a circular depression, around which may be 
seen three tubercles. When recently voided, the worms are somewhat 
transparent, so that the viscera may sometimes be seen through the pa- 
rietes. The integument is marked by circular fibres, and by four lines 
extending at equal distances from the head to the tail, the former of which 



684 worms. 

indicate" the course of the muscles, while the latter indicate that of the 
vessels and nerves. 

The color of the worm is whitish, yellowish, or more or less deep rosy 
in tint, according to the nature of the aliment they contain ; they are, as 
already stated, somewhat transparent when first voided. The alimentary 
canal, which may be distinguished by its brownish color, terminates by a 
transverse opening or anus, situated on the inferior surface of the animal, 
just in front of its posterior extremity. 

The two sexes are in different individuals. The male may be known 
by its tail, which is shortly curved, while that of the female is straighter 
and thicker. The genitals of the male consist of a double penis which 
may sometimes be seen to protrude just in front of the caudal extremity; 
those of the female may be distinguished by the vulva, seated at a con- 
stricted point of the body, about a third of the distance from the head to 
the tail. The male is smaller and much less abundant than the female. 

The Ascaris or Oxyuris vermicular is, thread-worm, seat-worm, or 
maw-worm, is the smallest of the intestinal worms, and is generally dis- 
tinguished in popular language by the title of ascarides. The sexes are 
in separate individuals. 

The male is generally about two lines in length ; its body is elastic, of 
a whitish color, very slender, and looks not unlike a piece of cotton thread, 
whence one of its names was derived. The female is larger than the 
male, reaching a length of four or five lines. The anterior part of the 
body is of the same shape in both sexes. It is obtuse, and surrounded 
by a transparent membrane, through which may be seen a straight tube, 
forming a kind of bladder, which is the oesophagus, and which terminates 
in a globular stomach. The head is provided with three tubercles, as 
in the lumbricoides. The intestinal tube in the male continues the whole 
length of the body, which becomes somewhat thicker towards the end, 
and is arranged into a spiral shape at the tail. The body of the female is 
shaped like that of the male as far back as the stomach, and increases in 
size in the first third of its length, after which it diminishes, and becomes 
so small at the end as to be seen with difficulty by the naked eye. 

The Tricocephalus dispar or long thread-worm is generally about an 
inch and a half or two inches long, and consists, as it were, of two por- 
tions, of which the anterior, constituting about two-thirds of the length, 
is exceedingly slender, scarcely thicker than a horse-hair, while the poste- 
rior third swells out suddenly so as to become much thicker and larger. 
The sexes are in different individuals. The worm is provided with an 
alimentary canal, which, commencing at an orbicular mouth placed in 
the small extremity, runs through the animal to the anus, placed at the 
caudal extremity. The male is smaller than the female, and is, usually, 



DESCRIPTION. 655 

found convoluted. This worm is met with chiefly in the caecum and 
colon, particularly the former. It usually exists in very small numbers, 
and often but a single one is found. The symptoms which it occasions 
are the same as those produced by the lumbricoides. 

The Taenia solium, common or long tape-worm, as well as the Taenia 
lata, are of rare occurrence in children. Of 206 cases observed by M. 
Wavruch, only twenty-two occurred in subjects under fifteen years of age, 
and of them the youngest was three years and a half old. (Bib. du Med. 
Prat. t. v., p. 626.) These worms have however been met with at an 
earlier age, but as they are rare, I deem it unnecessary to do more than 
describe their appearances, in order that the reader may be able to distin- 
guish between them and the varieties which generally exist in children, 
the Ascaris lumbricoides and vermicularis. For a full account of the 
symptoms produced by the two varieties of the taenia, and their treat- 
ment, the reader is referred to any of the standard works on the practice 
of medicine. 

The Taenia solium is usually of a whitish color, flat in form, and vary- 
ing in length from five to ten feet, its ordinary length, to sixty, or even, 
according to the assertion of some writers, upwards of a hundred. It is 
uneven in shape, being thick and rounded behind, and measuring three 
or four lines at its widest part, while it tapers gradually towards the an- 
terior extremity, where it becomes slender and thread-like. The head is 
minute in size, and flattish in shape, with a projecting papilla in the 
centre, furnished with a double circle of hooks, and surrounded by four 
cylindrical apertures, which seem to be the mouths of the animal. The 
body is composed of numerous segments, which are longer than broad at 
the posterior part of the worm, and resemble, when separated, the seeds 
of a gourd, and have hence been called cucurbitani. In this worm the 
two sexes exist in the same individual. 

The Bothriocephalic latus, Taenia lata, or broad tape-worm is long and 
flat like the preceding variety, but it is generally thinner and broader, mea- 
suring from four to ten lines in breadth. It sometimes attains, like the 
common tape-worm, to a very great length. It is usually of a dirty-white 
color, and rather less opaque than the Taenia solium. It is distinguished 
also, says Dr. Wood, from the other taenia, by the shape of the segments, 
which are broader than they are long ; by the form of the head, which is 
small, elongated, without spines, and divided into two lobes by a longi- 
tudinal fossa on each side; and by having, instead of the four mouths of 
the taenia, a single minute pore in the centre, between the fossae, or else 
two pores, one at the extremity of each lobe. 

The frequency of intestinal worms, and their importance as a cause of 
disease, have certainly been, and are still by many physicians, and espe- 



686 worms. 

cially by the public, very greatly exaggerated. There can be no doubt 
that they do, when they exist in large quantities, and particularly in cer- 
tain countries, give rise to grave disturbances of the digestive organs, and 
even occasion death ; but such instances are, it seems to me, extremely 
rare in this city at least. I am quite sure that I have never as yet met 
with a case in my own experience, in which life was at all seriously en- 
dangered by their existence, — though I have seen numerous instances in 
which slight disorders of the digestive apparatus, and various nervous 
symptoms, generally of very moderate severity, have disappeared after 
the administration of anthelmintics, sometimes followed, and in an equal 
number of cases probably, not followed, by the expulsion of worms. 

To show the truth of the above remarks, as to the importance of worms 
as a cause of disease, I make the following quotations. Dr. Rush (Med. 
Inquiries and Observations, vol. i. p. 205), remarks : " When we consider 
how universally worms are found in all young animals, and how frequent- 
ly they exist in the human body, without producing disease of any kind, 
it is natural to conclude, that they serve some useful and necessary pur- 
poses in the animal economy." M. Guersant says (Diet, de Med. t. xxx. 
669) : " It has always been the custom to assign to entozoa much too im- 
portant an influence upon the diseases of childhood. In proportion as 
this part of pathology is perfected, it becomes evident that the greater 
number of children dying after having discharged worms, or even while 
having them still, are affected with acute or chronic diseases, which leave 
after death incontestable traces of their effects, and which are of them- 
selves necessarily fatal." M. Barrier {Mai de VEnf. t. ii. p. 100), quotes 
M. Trousseau as making the following remarks. " For sixteen years we 
have not met with a single child who has presented any verminous symp- 
toms; never or almost never does' a child born and reared in Paris dis- 
charge worms, while just the contrary is true as to the provinces 

Young children, to be sure, are sometimes met with in our 

hospitals, who discharge worms, but they are those who have been born in 
the country, and have lived in the capital only for a short time." Dr. 
Condie (Dis. of Child. 2d ed. p. 226), remarks : " Worms are a very 
common occurrence in the intestines of children, and may unquestionably, 
under certain circumstances, become a cause of severe irritation ) — but 
much less frequently than is generally supposed." 

I believe we may conclude, therefore, that though these parasites are 
of very common occurrence, and productive of grave disorders in some 
countries, they are rarely met with in quantities sufficient to do serious 
injury to the health, in other places, as for instance, Paris, and probably 
in this country, or at least in the northern parts of it. 

That intestinal worms do, however, not unfrequently in some countries, 



ASCARIS LUMBRICOIDES. 687 

and occasionally in all, produce dangerous and even fatal disturbances of 
the health, cannot be doubted after careful perusal of the evidence brought 
forward by different authorities. M. Guersant, amongst others, remarks 
(Loc. cit. p. 670): "It is nevertheless incontestable, that the develop- 
ment of these animals in the gastro-intestinal and abdominal cavities, 
does sometimes give rise to very varied morbid phenomena, which are in 
some instances grave enough to cause death/' Nevertheless, I am dis- 
posed to believe, as stated above, that fatal, or even dangerous results 
from the existence of these parasites, are of rare occurrence in this city, 
and probably throughout our Northern States. Dr. Dewees, however, 
mentions several cases in which they produced alarming symptoms, and 
one in particular (Lis. of Child, p. 492), in which the subject, a child 
twenty months old, was extremely emaciated, and whose abdomen was 
"enormously distended, and semi-transparent," who recovered rapidly 
after ninety-six lumbricoides, from six to ten inches long each, had been 
expelled under the use of pink-root in infusion. 



ARTICLE I. 



ASCARIS LUMBRICOIDES. 



The description of this worm has already been given at page 683. 

Causes. — Under this head I shall not pretend to consider the question 
of the origin of worms, but only the causes which predispose to their 
production, or favor their growth. 

Age has no doubt a considerable influence upon the predisposition to 
lumbricoides. According to M. Guersant {Loc. cit. p. 685), infants at 
the breast under six months of age are very rarely affected with them. 
Instances occasionally occur, but are altogether exceptions to the general 
rule. Above six months of age, they begin to be met with, but still 
very rarely, so that scarcely one or two will be found in several hundred 
children of a very early age ; while from three to ten years of age they 
will be observed in about a twentieth, or in some seasons perhaps in a 
larger proportion. M. Valleix states that he has never met with them 
in new-born children. Dr. Dewees says {Loc. cit. p. 481), that he has 
never seen worms in children under ten months old ; and in only two in- 
stances at that age. I do not recollect myself ever to have seen them in 
subjects younger than eighteen months, and very rarely in those under 
three or four years. 

There can be little doubt that the disposition to worms is hereditary in 
some families. It is generally believed that the species under considera- 



688 worms. 

tion is more common in girls than boys ; that it is most common in chil- 
dren of lymphatic and scrofulous constitution ; and that a too exclusively 
vegetable or milk diet, and an abuse of fruits, strongly predispose to 
their production. The habitation of a cold and damp, or warm and 
damp climate, and the seasons of summer and autumn, are supposed by 
many also to favor their production and growth. It is a general belief, 
and I should suppose from personal experience, a well-founded one, that a 
feeble and disordered state of the digestive function from any cause, often 
acts as a predisposing cause of worms, and particularly of lumbricoides. 

Seat. — The small intestine is, in a very large majority of the cases, 
the seat of the ascaris lumbricoides. They are met with, however, in 
other parts of the digestive tube, particularly the stomach and large in- 
testine, and more rarely in the oesophagus or pharynx. In some instances 
they are found to have migrated to other organs, as to the liver, gall- 
bladder, and in still rarer cases, they have passed into the peritoneal 
cavity, bladder, larynx, trachea, bronchia, and even into the nasal pas- 
sages and frontal sinuses. They have also been met with occasionally in 
the walls of the abdomen, forming verminous abscesses, whence they 
have escaped on the opening of the abscess. 

The number of ascarides is exceedingly variable ; there may be only 
two or three, ten or twenty, or several hundred. When very numerous, 
they are apt to be rolled or twisted into knots or balls, which have been 
seen as large as the fist, so as to block up completely the canal of the in- 
testine. In a case cited by Rilliet and Barthez, from M. Daquin, the 
duodenum was so filled with worms as to be distended and to have ac- 
quired a considerably larger size than natural, while at the same time 
it was hard and elastic. The jejunum, ileum, and caecum were filled, so 
that it seemed as though the worms must have been pushed in by force. 
They were found also, but in smaller quantity, in the colon. Dr. Condie 
{Loc. cit. p. 230), states that he has known one hundred and twenty 
lumbricoides to be voided in a single day, by a child five years old. It 
ought, however, to be remarked, that the instances in which such large 
numbers are met with are altogether exceptional, especially in our North- 
ern States. I have never myself known more than six, eight, or ten to 
be expelled, within a few days' time, and very generally there have not 
been more than three, four, or five. 

Anatomical Lesions. — When the number of lumbricoides is small, 
the mucous membrane has been found in a state of perfect health, while, 
on the contrary, when they were numerous, and especially when collected 
together into knots, the membrane has presented a fine injection like that 
which exists in erythematous enteritis ; in some very rare instances on 
record, in which the quantity of worms has been very great, the mucous 



ANATOMICAL LESIONS. 689 

membrane has been found deeply injected, thickened, granulated, and in 
a smaller proportion of cases, softened, and even eroded. Not unfre- 
quently the intestine presents all the characters of well-marked enteritis, 
or entero-colitis, though the number of worms may be very small. In 
such cases it is reasonable to suppose that the inflammatory affection has 
been an accidental complication of the verminous disorder. 

Much discussion has arisen in regard to the manner in which perfora- 
tion of the intestine as an accompaniment of worms takes place. It is 
necessary to suppose, in subjects in whom worms are found in the perito- 
neal cavity, or in abscesses formed in the abdominal parietes, that perfo- 
ration of the bowel has taken place, and yet in some instances no trace 
of the opening is left, no inflammation of the serous membrane is met 
with, nor has there been any escape of the contents of the digestive canal 
into the abdominal cavity. In others, however, and much the most nu- 
merous cases, it is evident from the anatomical appearances, that the per- 
foration has taken place in consequence of previous ulceration of the coats 
of the bowel, and that the worms have escaped with the other contents of 
the intestine. It is in regard to the former class, therefore, that discus- 
sion has principally taken place ; some asserting that the parasite itself 
makes the opening, by an active process, while others deny the possibility 
of this occurrence, and maintain a previous ulceration or softening in all 
cases. Amongst those who advocate the possibility of perforation inde- 
pendent of previous change in the intestinal coats by disease, are MM. 
Mondiere and Charcelay, the former of whom has examined the subject 
with a great deal of care, quoted by Billiet and Barthez ; Rilliet and 
Barthez themselves; the authors of the Bibliotli. du Med. Prat., and M. 
Guersant; while amongst those opposed to this opinion may be cited, 
MM. Cruveilhier, Barrier, Dr. Arthur Farre, who greatly doubts the pos- 
sibility of the accident, and Dr. Condie. I confess myself inclined to 
believe from facts stated by different authors, and from the history of two 
cases which occurred to M. Guersant in 1841, at the Children's Hospital 
of Paris (Loc. cit. p. 680), that worms may in some instances cause a 
perforation independently of previous disease of the coats of the intes- 
tine. In one of these, two lumbrici were found engaged in an opening 
in the appendix vermiformis, half the bodies of the animals being in the 
appendix, and half in the peritoneal sac ; while in the other, an opening 
of the same kind as in the previous case was found in the appendix, and 
though the three worms which were found lying in the abdominal cavity, 
might have escaped through an ulcerated perforation of the colon, it is 
not the less true that the opening in the appendix presented the same 
characters exactly as in the first case, in which the animals were, as the 
author remarks, "fcaken in the act." In both instances, the perforation 

44 



690 ASCARIS LUMBRICOIDES. 

of the appendage was at the extremity of that canal, and in the form of 
a narrow opening of a conical shape; the membranes were smooth, thin- 
ned, and the edges of the orifice sloped off from within outwards; no trace 
of anterior ulceration was perceptible. 

In regard to the verminous abscesses already referred to, I shall make 
but few remarks, referring the reader to more extensive treatises for fuller 
information. These abscesses have been, in very rare instances, met with 
in the pharynx and nasal passages, but much more frequently they exist 
in the abdomen. The latter may be of two kinds, stercoraceous and non- 
stercoraceous. In the former, the abscess which forms upon some portion 
of the walls of the abdomen, gives issue not only to the worm or worms, 
and pus, but also to faecal and even alimentary substances, and leaves 
behind a fistula connecting with the cavity of the intestine, which may 
cicatrize after a short time, or remain open during life. In the other 
form of abscess, the opening through the coats of the intestine has been 
closed immediately after the passage of the worm, so that the abscess 
gives issue only to the animal and pus, after which it heals up without 
giving rise to a fistula. 

The verminous abscesses are said to be found generally about the 
inguinal and umbilical regions; to occur most frequently between the 
ages of seven and fourteen years, and not to be, as a general rule, very 
dangerous to life. 

Symptoms Indicative of the Presence of Worms. — I believe it is 
almost universally acknowledged by later writers, that there is no single 
symptom, nor group of symptoms, other than the expulsion of the worms, 
and their detection, which indicate with certainty their existence in the 
digestive tube. This is the expressed opinion, amongst others, of MM. 
Guersant, Rilliet and Barthez, Barrier, Valleix, and Drs. Eberle and 
Condie, and it is also the opinion which I have myself been led to form 
from my experience amongst children. 

Another point worthy of remark is, that even though one or several 
worms may have been expelled, it is not always fair to conclude that the 
symptoms under which the child labors, are the result of the presence of 
others of these animals, as there may be no more in the bowels, or they 
may be so few in number as not to produce injurious effects ; while, on 
the contrary, various disorders of the digestive tube, as chronic indiges- 
tion, simple diarrhoea, and inflammatory diseases of the gastro-intestinal 
mucous membrane, may and do exist simultaneously with, and yet inde- 
pendently of, the presence of these parasites. 

The symptoms generally enumerated as indicative of the presence of 
worms are the following. The child presents various signs of disturbed 
health. The stomach is more or less deranged, as shown by furred 



SYMPTOMS. 691 

tongue, eructations, variable appetite, which is sometimes diminished, 
and sometimes increased, thirst, acid or heavy breath, and nausea. The 
abdomen may be enlarged or retracted, generally the former, and is often 
more or less hard and painful to the touch ; the condition of the bowels 
varies in different cases, as they are sometimes costive, and sometimes 
affected with diarrhoea. According to M. G-uersant, the stools often 
contain glairy substances, and are sometimes streaked with blood and of 
a yellowish-green color ; the patient often suffers from colics, which may 
be either dull or acute, though more generally the latter, and which are 
generally felt at the umbilical region. Children affected with lumbricoides 
are said to present a peculiar physiognomy : the face is usually paler than 
natural, and sometimes has a leaden tint ; the eyes are surrounded by 
bluish rings, and have at the same time a dull and languid expression ; 
the inferior eyelids are often swelled and puffy; the sclerotic coat of the 
eye assumes a bilious tint; the nostrils are said to be sometimes swelled 
and the child complains much of irritation and itching of those parts, 
and is constantly picking at them with the fingers. In some instances 
epistaxis takes place. The child is generally pale and thin, indolent and 
languid, or irritable and unhappy. The sleep is almost always disturbed. 
This indeed, is, it seems to me, one of the most important signs both of 
worms and of chronic functional disorders of the stomach and bowels. 
The nights are almost always restless, the patient either waking often 
and wanting to drink, or waking in fright and alarm from dreams, or else 
constantly tossing and turning in sleep, moaning, or grinding the teeth. 

Other symptoms mentioned by different observers, and by some very 
much depended upon, are acceleration with irregularity of the pulse, and 
dilatation, especially unequal dilatation, of the pupils. I may cite also 
strabismus, and occasional cough. 

In children in whom the number of lumbricoides is very large, the 
constitution suffers to a dangerous degree. The symptoms above enume- 
rated are very marked, and at the same time the child is very pale or 
sallow, emaciated, weak, and without appetite ; the abdomen is hard and 
tumid; the nervous symptoms are severe, and some of the symptoms 
which I shall describe presently, under the head of disorders occasioned 
by worms, are also observed. 

It should be remarked, however, again, that all or any of the symptoms 
just described may exist independently of the presence of worms, the only 
certain sign of which is their expulsion from the patient. 

Morbid Effects Occasioned by Worms. — MM. Rilliet and Barthez 
divide the accidents or effects produced by the existence of lumbricoides 
into two groups : those which result from the mechanical influence of the 
entozoa, as, their accumulation or displacement; and those which appear 



692 ASCARIS LUMBRICOIDES. 

to be the consequences of a purely sympathetic action on the different 
systems of the body, and particularly the nervous system. 

Mechanical Effects. — Under this head are included perforation and 
hemorrhage of the intestine, enteritis, abscesses, and the symptoms de- 
termined by the displacement or migration of the worms into the ductus 
communis choledochus, liver, or air-passages. 

Of perforation and abscesses I have already treated under the head of 
anatomical lesions. Hemorrhage is a very rare event, but occurred in 
one instance cited by MM. Rilliet and Barthez, and Guersant, from M. 
Charcelay, in consequence of the rupture of an arteriole in a small rounded 
ulceration in the duodenum, apparently occasioned by the presence of a 
large number of lumbrici. Enteritis, as an effect of the presence of 
worms, has also been referred to under the head of the anatomical lesions. 
In many instances it is no doubt a mere accidental complication, in no 
way connected with the presence of entozoa; probably this is true of a 
large majority of the cases. When, however, the number of the parasites 
is very great, and particularly when they are collected into large or firm 
knots and bundles, they may, no doubt, occasion, by their mechanical 
irritation, inflammation, thickening, softening, and even destruction of 
the mucous tissue, as in cases cited by M. Guersant, from MM. Breton- 
neau and Charcelay, and in one which occurred to himself. It should be 
remarked, however, that the cases on record in which ulcerations evidently 
depended upon the presence of worms, are, so to speak, infinitely few in 
comparison with those in which no such alteration existed, or in which it 
was evidently independent of any influence exerted by the worms. 

Effects Caused by the Displacement or Migration of Wor ms- 
— Lumbricoides have been found, as we have already seen, in the walls 
of the abdomen, giving rise to abscesses. They have been discovered also 
in the ductus communis choledochus, in the gall-bladder, hepatic ducts, 
in the substance of the liver forming abscesses, and in the pancreatic 
canal. The symptoms occasioned by the latter class of cases are very 
obscure. In one instance, M. Guersant supposed that an attack of con- 
vulsions depended upon the presence of worms in the common duct. 

More numerous examples are on record, in which violent dyspnoea and 
cough, or fatal asphyxia, have occurred in consequence of the pressure of 
lumbricoides, which had passed into the oesophagus, or from their intro- 
duction into the larynx, trachea, or bronchia. The symptoms occasioned 
by these accidents are a sudden attack of dyspnoea, anxiety, agitation, 
threatened suffocation, dry, spasmodic cough, acute, painful cries, pain in 
the larynx or trrchea, and unless relief be obtained in a few hours, death. 
This kind of attack may depend on the rising of a worm or bundle of 
worms into the oesophagus, causing pressure on the larynx and trachea, 



SYMPTOMS. 693 

as in the case reported by M. Tonnelle, in which the symptoms disap- 
peared after the expulsion of a large number of worms. I met with an 
instance of this kind myself. It occurred in a boy fifteen years old, 
presenting every mark of strong and vigorous health, but who for three 
or four weeks before I was consulted in regard to him, had been subject 
to sudden and apparently causeless attacks of suffocation, which seized 
him without the least warning. When the attack came on, he would for 
some instants cease to breathe, or breathe with much difficulty. He 
always seemed to suffer from the greatest anxiety ; the countenance be- 
came altered and distressed ; he was unable to speak, but made signs for 
water, and when able to swallow a mouthful, which was always exceed- 
ingly difficult, was at once relieved. His mother told me that he always 
appeared to be in the greatest distress, so that on several occasions, she 
feared for his life. Striking him violently on the back, which she, when 
present, always did, sometimes relieved him, but generally the difficulty 
continued until he could swallow a little fluid of some kind. These 
attacks were unattended at the time by cough, nor was there the least 
sign of disorder of the respiratory system in the intervals between them. 
Suspecting that the difficulty must depend on the rising of a worm or 
worms into the oesophagus, or upon sympathetic irritation from the pre- 
sence of these parasites in the stomach, and learning that he had been 
troubled with worms some years previously, I gave him wormseed oil, 
which caused the expulsion of a few large lumbricoides, after which he 
had no return of the symptoms. 

The attacks of dyspnoea may depend also, as already stated, on the 
introduction of worms into the air-passages. Under these circumstances 
death is very apt to be the result. In one instance, however, reported by 
M. Arronssohn, after the difficulty had lasted two hours, the patient, a 
little girl eight years old, after violent efforts at coughing, threw up a 
living lumbricus. 

We have next to consider the sympathetic effects, and particularly the 
nervous symptoms, occasioned by worms. We may include amongst the 
nervous symptoms produced by worms the headache, languor, irritability, 
restless and disturbed sleep, and grinding of the teeth, so frequently ob- 
served. These, however, are of but slight importance in comparison with 
certain other disorders of the nervous system, which do undoubtedly 
occur sometimes, though I should suppose very rarely, in proportion to the 
whole number of subjects affected with the parasites. The disorders to 
which I allude are partial or general convulsions, chorea, hysteria, cata- 
lepsy, and epilepsy, which are the most frequent, though, as so often 
stated already, extremely rare in comparison with the number of cases in 
which the presence of the worms produces no such effects. Other disor- 



694 ASCARIS LUMBRICOIDES. 

tiers cited by the authors of the Bib. du Med. Prat., with cases to prove 
their reality, are insanity, paralysis, coma, palpitations, strabismus 
cough, hyperesthesia of the skin, amaurosis, and aphonia. 

Diagnosis. — It has already been stated that there are no certain signs 
of the presence of worms in an individual except their expulsion. The 
symptoms which have seemed to me most strongly to indicate their pre- 
sence are a chronic disordered state of the digestive apparatus, producing 
irregular appetite, which is sometimes good and at others bad ; slight ema- 
ciation; paleness or unhealthy tint of the complexion; languid expression 
of the face ; some irritability of the temper, or a want of the gayety and 
activity of disposition natural to childhood ; picking at the nose ; often 
some tumidity of the abdomen, which may be at the same time either 
hard or merely tympanitic ; and what seems to me more important than 
any that I have named, very restless and broken sleep at night, with 
frequent grinding of the teeth. 

M. Valleix remarks that, in a case presenting nervous symptoms simu- 
lating disease of the brain, we may suspect the existence of worms, if we 
learn upon inquiry that symptoms of marked intestinal disorder, the 
various signs cited above as indicative of the presence of worms, and 
different derangements of digestion, had preceded for some time the 
appearance of the nervous symptoms ; chiefly for the reason that in most 
diseases of the brain, the digestive tube is, at the invasion, in a state of 
integrity, with the exception of sympathetic vomiting. If we can learn, 
upon inquiry, that the child has discharged worms on some previous oc- 
casion, the probability of the dependence of the symptoms upon them 
becomes still stronger. 

It is sometimes difficult to determine positively whether certain sub- 
stances discharged at stool are fragments of worms, or whether they are 
portions of imperfectly digested aliment, or foreign bodies. The things 
which most resemble lumbricoides, are the remains of tendons, ligaments, 
vessels, fibres of plants, etc. To make the distinction with certainty, the 
doubtful substance ought to be placed in water, so that it may be tho- 
roughly cleansed, after which it must be carefully examined as to its 
structure, arrangement, consistence, etc., with the eye, and with the mi- 
croscope, if necessary. M. Guersant has suggested a very easy method 
of ascertaining whether the substance be animal or vegetable, which is to 
subject it to heat, after it has been carefully washed, when the odor will 
at once inform us of its real nature. 

Prognosis. — It is no doubt a very rare event, at least in the northern 
parts of our country, for life to be endangered by the presence of worms. 
I have never, myself, met with an instance in which the general health 
was more than moderately disturbed by this cause. That verminous 



TREATMENT. 695 

affections are sometimes, however, dangerous to life in this city, is shown 
by three cases related by Dr. Dewees, in which very severe and threaten- 
ing symptoms were instantly relieved upon the expulsion of lumbrici after 
the exhibition of vermifuges. 

Worms become dangerous to life when they migrate from their original 
seat to neighboring and important organs, particularly the air-passages 
and liver. The prognosis is unfavorable also when they accumulate in 
very large numbers, and give rise to the different nervous symptoms 
above described. 

Treatment. — Before commencing my remarks upon the particular 
remedies employed for the destruction and expulsion of worms from the 
alimentary canal, I would call the attention of the reader to the fact that 
most of the recognised anthelmintics are more or less irritating to the 
gastro-intestinal mucous membrane, and some of them to the nervous 
system also, producing in over doses, severe and even dangerous nervous 
symptoms. It is evident, therefore, that remedies of this class ought not 
to be exhibited unless they are manifestly called for, and not at all when 
symptoms of severe gastro-intestinal irritation, and particularly of inflam- 
mation, are present, unless there be the very strongest reasons for sup- 
posing that those symptoms depend upon accumulations of worms. I am 
quite sure that I have, in a considerable number of instances, met with 
children whose digestive organs had been injured, and in whom slight 
functional derangement had been converted into severe indigestion, and 
even inflammatory disorder, by the too frequent or long-continued use, or 
the administration in excessive quantities, of different vermifuges, and of 
various quack nostrums, which are sold to an amazing extent in this city, 
at least, and no doubt all over the country. 

As the diagnosis of worms is always doubtful, it is best never to risk 
the administration of any of the irritating vermifuges, unless convinced, by 
the previous expulsion of worms, that they are almost certainly present; 
and, indeed, I myself rarely give any other remedy than small quantities of 
the icormseed oil in slight, and especially in doubtful cases, unless this 
has already been tried and failed. From my own experience I believe 
that this remedy is all-sufficient in a large majority of the cases that 
occur in this city, as these are almost always of a mild character, and as it 
not only produces the expulsion of the parasites when they exist, but 
also acts beneficially upon the forms of digestive irritation which simu- 
late so closely the symptoms produced by worms. I am persuaded, in- 
deed, that of all the cases that have come under my notice, in which it 
seemed probable that worms might be present, none were expelled in 
nearly half, and yet the signs of disturbed health have passed away 
under the use of the remedy. The oil of wormseed may be given in doses 



696 



ASCARIS LUMBRICOIDES. 



of four drops to children of two years of age, and of six or eight to those 
above that age, three times a day for three days, to he followed on the 
morning of the fourth day by a moderately active, but not irritating ca- 
thartic dose, the best of which is castor oil or syrup of rhubarb. The 
objection to the remedy is its nauseous taste and smell ; these, however, 
may be partially concealed by making it into a mixture with yolk of egg, 
powdered gum, and syrup of ginger. Some children take it very well 
dropped upon a lump of white sugar, while others take it best mixed 
with common brown sugar. If one course of the oil, as it is called, fail 
to relieve the symptoms, another should be administered. It ought to 
be recollected that when given in large doses, the wormseed oil is irri- 
tating to the digestive mucous membrane, and produces dangerous ner- 
vous symptoms. I know of one case in which a girl six or seven years 
of age was made exceedingly ill, and suffered for years afterwards from 
the effects of a teaspoonful of the oil given by mistake. 

The wormseed may be given also in powder, in the dose of from twenty 
to forty grains. 

The remedies most frequently employed in this country besides the 
wormseed, are pink-root or spigelia, oil of turpentine, calomel, and the 
bristles of cowhage. 

I believe that the pink-root is more depended upon amongst us than 
any other single remedy. It is given either in substance or infusion. 
The dose of the powder is from ten to twenty grains for a child three or 
four years old, to be repeated every morning and evening for several days, 
and followed by an active cathartic. It is seldom used, however, in this 
way, but almost always in infusion. The best and safest mode of admi- 
nistering it is in combination with cathartic substances. Thus, half an 
ounce each of pink-root and senna may be infused for a few hours in a 
pint of boiling water, and a tablespoonful given two or three times a day, 
to children two or three years old, for three, four, or five days, when it 
should be suspended for a time, and resumed, if necessary. A prepara- 
tion much used in this city under the title of worm tea, and which I have 
myself given with very good success, consists of the spigelia mixed with 
senna, manna, and savine, in different proportions, made into an infusion 
and sweetened with brown sugar. Dr. Gr. B. Wood (Pract. of Med., vol. 
i. p. 626), recommends the following formula 



R. 



-Sennse, Spigelise, . 
Magnesise Sulphat. 
Mannae, . . . 
Foeniculi, . . . 
Aquae fervent., 



II ss. 



311. 
Oj. 



These are to be macerated for two hours in a covered vessel, and a table- 



TREATMENT. 



697 



spoonful given to a child two years old once or twice a day, or every other 
day, so as to procure two or three evacuations in the twenty-four hours. 
The remedy is continued for a few days, or for one or two weeks, if ne- 
cessary, and if it do not debilitate the child. 

The spirits of turpentine are highly recommended as an efficient remedy 
for worms by several authorities, and particularly by Dr. Joseph Klapp 
and Dr. Condie of this city. Dr. Condie states that it is the article from 
which he has derived the most decidedly beneficial effects, and remarks 
that it may be given when there exists considerable irritation of the ali- 
mentary canal, or even subacute inflammation, without any fear of its 
increasing either. He gives the rectified spirits in sweetened milk, in 
molasses, or in the following mixture : 

R. — MuciL G. Acacia?, ^ii. 

Sacch. alb., £x. 

Spir. iEther. nitr., ^iii. 

Spir. Terebenth. rec, giii. 

Magnes. Calcinat., ^i. 

Aquae Mentha?, 31. — M. 

Of this mixture a dessert spoonful is given every three hours. 

I have used the spirits of turpentine but once, on account of its extremely 
disagreeable taste, having up to this time always succeeded perfectly well 
with the wormseed oil, or with infusion of pink-root with cathartics. 

Calomel also, is highly thought of by many persons as a vermifuge, 
and, no doubt, when used in combination with, or followed by cathar- 
tics, or given in full purgative doses, it is very effectual. I can only re- 
peat what I have already said on several occasions, that it is a remedy 
which, from the powerful influence it exerts upon the constitution, ought 
not to be given except when really called for ; and, as we can almost 
always succeed in curing verminous affections by milder drugs, I see no 
occasion for resorting to this, except in rare cases. When used it is given 
alone in considerable doses, and followed by some cathartic, or in combi- 
nation with rhubarb and jalap, or jalap or scammony. 

The bristles or down of eowhage are also used by some practitioners, 
no doubt sometimes with success. I have never used them, and can give 
no opinion, therefore, from personal experience, as to their efficacy. They 
are administered by making them into an electuary with honey, syrup, or 
molasses, a teaspoonful of which is given every morning for three days, 
and then followed by an active cathartic. 

The following electuary, recommended by Bremser, is very much em- 
ployed in Europe, and is highly spoken of by Dr. Eberle : 



698 ASCARIS LTJMBRICOIDES. 

R. — Semin. Santonicse (semen-contra of the French "writers), 

Semin. Tanaceti rude contus., aa ^ss. 

Valerian, pulv., 2[ii. 

Jalaprc pulv., ^iss-ii. 

Potass. Sulphat., giss-ii. 

Oxymel. Scilhe, q. s.— ut. ft. 

Electuarium. 

A teaspooiiful of this is given morning and evening for three or four days, 
when the dejections generally become more copious and liquid. If it 
do not produce this effect, Bremser advises that the dose be increased. 
Dr. Eberle gave it for six or seven days, and says it does far less good 
when it produces frequent and watery evacuations, than when it causes 
only three or four consistent stools a day. This preparation has a very 
disagreeable taste, and children sometimes refuse to take it on that ac- 
count. When this is the case it may be made into pills. 

Rilliet and Barthez recommend the following syrup, which was pro- 
posed and highly thought of by M. Cruveilhier : 

It. — Follicul. Sennse, Khei, Semin. Santonic, Artexn. Abrotan., 

Helminthocort., Taneceti, Artemis. Pontic, aa 31. 

To be infused in half a pint of cold water, strained, and made into a syrup with 
sugar, of which a tablespoonful is to be given every morning for three days. 

M. Cruveilhier states that this syrup has been very successful in his 
hands. The empyreumatic oil of Chabert is also highly spoken of by 
some European authorities. It is made by mixing one part of the empy- 
reumatic oil or fetid spirits of hartshorn, with three parts of spirits of 
turpentine, and allowing them to digest for four days. The mixture is 
then put into a glass retort, and distilled in a sand-bath until three-fourths 
of the whole have passed over into the receiver. The product should be 
kept in small and tightly-closed phials. The dose is about fifteen or 
twenty drops three or four times a day, for children between two and 
seven years old. This is recommended highly by Bremser and other 
authorities. The great objection to it is its exceedingly nauseous taste. 
Dr. Eberle speaks in very favorable terms of a strong decoction of hel- 
minthocorton or Corsican moss, which he has found " not only valuable 
as a vermifuge, but particularly so, as a corrective of that deranged and 
debilitated condition of the alimentary canal favoring the production of 
worms." An ounce of helminthocorton, with a drachm of valerian, are 
to be boiled in a pint of water down to a gill, and a teaspoonful of the 
decoction given morning, noon, and evening. It is particularly beneficial 
in cases attended with the usual symptoms of worms, connected with 



TREATMENT. 699 

want of appetite and mucous diarrhoea, and arising from debility of the 
digestive organs, and vitiated condition of the intestinal secretions. 

In all cases of deranged health supposed, either from the nature of the 
symptoms, or proved by the previous expulsion of worms, to depend on 
the presence of these animals in the alimentary canal, it is exceedingly 
important to attend to the hygienic treatment of the child, and in some 
instances to administer tonics and stimulants. In not a few cases that have 
come under my own notice, in which many of the symptoms supposed to 
indicate the presence of worms have been extremely well-marked, I have 
succeeded in removing them all without a resort to any vermifuge, by the 
treatment proper for the chronic indigestion or dyspepsia of children. 
The method of treatment to be employed in such cases has already been 
laid down in the article on indigestion, to which the reader is referred for 
full information. It should consist chiefly in strict attention to exercise 
and diet, and in the use of tonics, as quinine and iron, and small quanti- 
ties of fine port wine. 

Whenever any complication exists in connexion with worms, the treat- 
ment must be modified according to the nature of the complication. If 
it consist in inflammation of any part of the digestive tube, the inflam- 
mation ought to be attended to first, and the verminous disorder for the 
time neglected. If the inflammation be very slight, or, if the symptoms 
indicate only severe irritation rather than positive inflammatory action, we 
may exhibit the milder and least injurious vermifuges, as very small doses 
of wormseed oil, which I have never known to do harm, the decoction of 
helminthocorton and valerian, recommended by Dr. Eberle, or, according to 
Dr. Condie, the spirits of turpentine. If the verminous affection coexist 
with any of the acute local inflammations of the thorax, the former ought 
to be, as a general rule, neglected, until the latter has been relieved by ap- 
propriate treatment. In doubtful cases, in which it is impossible to ascer- 
tain with certainty whether the symptoms depend on worms, or upon a 
simple dyspeptic condition of the digestive organs, it is most prudent to 
give only the simplest and least irritating vermifuges, to regulate the 
hygienic conditions of the patient, and afterwards to resort to tonics, if 
necessary. 

Various writers, and particularly M. G-uersant, advise that we should 
forbid, in verminous cases, the use of relaxing food, especially of milk 
preparations, fruits, and of fatty and farinaceous substances; and that, 
after the expulsion of the worms, we should direct a tonic and strength- 
ening regimen. The diet should consist of boiled and roasted meats, of 
wine, and of bitters. The author just quoted, states that a change of 
food alone will often sufiice to procure the expulsion of worms. He says 
(Diet, de Med. t. xxx. p. 689), " I have met with children who had been 



700 ASCARIS VERMICULARIS. 

tormented with ascarides lumbrieoides while residing in the country and 
living upon milk and fruits, and who, upon being brought to the city, and 
put upon the use of broths and soups, passed considerable quantities of 
worms, and after that got entirely rid of them." 



ARTICLE II. 

ASCARIS VERMICULARIS. 

The description of this worm has already been given at page 684. 

Seat. — The ascaris vermicularis is found almost exclusively in the 
large intestine, and in a large majority of the cases is confined to the 
rectum. It is said to have been found in the vagina in the female, hav- 
ing no doubt passed from the rectum into that can'al. 

The causes of this worm are not at all understood. 

Symptoms. — The characteristic, and often the only symptom indicative 
of their presence, is violent itching about the anus, which is sometimes 
almost insupportable, and which is generally most troublesome and most 
apt to occur at night, when the child is in bed. In some instances they 
give rise to acute and violent pains in the region of the anus, and some- 
times to tenesmus and mucous or bloody stools. When the last-named 
severe symptoms exist, the worms may occasion dangerous nervous disor- 
ders, and even give rise to general convulsions. The worms not unfre- 
quently escape from the rectum and are found upon the bedclothes, or 
upon the clothes which the child has worn through the day. Sometimes 
they are discharged in considerable numbers, and are found in that case, 
either mixed with the fasces, or with mucus, or collected into balls or 
knots. 

The diagnosis of the seat-worm, like that of the lumbrieoides, cannot 
be regarded as positive, unless some have been expelled, or unless they 
can be seen by examination of the rectum. This can generally be done 
when they are present in any number, by pressing the nates apart so as 
to open the anus and bring the folds of the mucous coat of the bowel 
into view. The only other symptom which indicates their presence with 
any certainty, is the existence of severe itching about the anus, not to be 
explained upon any more reasonable supposition. 

Prognosis. — These worms do not, as a general rule, produce the same 
disturbances of the general health, as lumbrieoides, and in not a few in- 
stances, are entirely innocuous, with the exception of the pain an# incon- 
venience they occasion. 

They are, however, exceedingly troublesome, because of the difficulty 
of removing them entirely by any treatment. No matter how many are 



TREATMENT. 701 

discharged, some almost always remain concealed in the folds of the mu- 
cous membrane, and as they are propagated with great rapidity, the same 
train of symptoms is very apt to return soon after they may have been 
seemingly dislodged. 

Treatment. — It has been found by long experience that the common 
vermifuges given by the mouth, exert much less influence in causing the 
expulsion of these worms than of the lumbricoides. For this rer.son 
eneinata are generally resorted to in the treatment, instead of remedies 
given per orem. Dr. Dewees, however, recommends the elixir proprietatis 
(tinct. aloes et myrrhse), in small and often-repeated doses, continued for 
some time, and followed by enemata of lime-water, camphor, or aloes. He 
gave twenty drops of the elixir three times a day, in a little sweetened 
milk, to children from two to four years old, and thirty drops to those 
between five and seven years. 

The plan I have generally resorted to has been to give small doses of 
the wormseed oil, as directed in the article on lumbricoides, and to direct 
an injection of from four to six grains of powdered aloes, suspended in a 
gill of warm milk, for children four years old, to be repeated once in 
three, four, or five days, according to the necessity of the case. 

Lime-water by injection is recommended by several different authori- 
ties. It may be given of its ordinary strength, or mixed with an equal 
quantity of warm milk, or flaxseed mucilage. Other enemata recom- 
mended are spirits of turpentine in milk, a teaspoonful of the former to 
a gill of the latter; decoction of helminthocorton ; an injection made by 
infusing two drachms of fresh garlic-cloves in three ounces and a half of 
boiling water, and adding to the infusion, after it has been poured off, a 
scruple of assafoetida rubbed up with the yolk of an egg ; a solution of 
from six to twelve grains of sulphuret of potassium in half a pint of 
water; injections of sweet oil, or of lard beaten up with water until it 
becomes fluid, and even of cold water. The three last-mentioned sub- 
stances have the advantage of calming the itching and irritation of the 
rectum almost immediately. Again, it has been recommended to pass a 
bougie smeared with mercurial ointment into the rectum. I should much 
prefer a method of using this ointment which succeeded in the hands 
of M. Cruveilheir in a very severe case. This was to place a little of the 
ointment on the anus, by which course the patient was entirely relieved 
after a few days. M. Valleix states that he has obtained the same results 
by causing the anus to be anointed with the following preparation, a 
small quantity of which was introduced at the same time into the inferior 
extremity of the intestine : 

R. — Hydrarg. Chlor. Mitis, . « 9iv. 

Axung., ^vi. — M. 



702 , ASCARIS VERMICULARIS. 

Dr. Wood states that a dose of sulphur taken every morning before 
breakfast has been found very useful. 

The diet and general health ought always to be strictly inquired after, 
and attended to by the physician. For information upon these points 
the reader is referred to the remarks upon hygienic treatment in the last 
article. 



INDEX. 



Abdomen, examination of, . . 46 
signs from, . . .46, 47 

Acarus scabiei, .... 638 

Angina maligna. See Pseudo- 
membranosa pharyngitis. 

Angina simplex. See Simple pha- 
ryngitis. 

Aphthae, 230 

forms, .... 230 

causes, 231 

symptoms, . . . 231 

diagnosis, .... 231 

prognosis, . . , . 231 

treatment, .... 232 

Aphtha lactamen. See Thrush. 

Apoplexy, Cerebral and Meningeal. 
See Cerebral hemorrhage. 

Ascaris lumbricoides, description of, 683 

causes, .... 687 

seat, 688 

anatomical lesions, . . 688 
symptoms indicative of pre- 
sence of, . . . . 690 
morbid effects occasioned by, 691 
mechanical effects occasioned 

by, 692 

effects caused by displace- 
ment or migration of, . 692 
diagnosis, .... 694 
prognosis, .... 694 
treatment, . . . 695 

Ascaris vermicularis, description of, 684 

seat, 700 

symptoms, . . . 700 

diagnosis and prognosis, . 700 

treatment, .... 701 



Asthma, thymic, .... 443 

Atelectasis, post-natal, or collapse 

of the lungs, ... 123 

general remarks, . . . 123 

anatomical lesions, . . 126 

causes, 128 

symptoms, .... 131 

diagnosis, .... 134 

prognosis, .... 135 

treatment, .... 136 

Atelectasis pulmonum, congenital, 115 

anatomical appearances, . 115 

causes, 116 

symptoms, . . . 116 

diagnosis, .... 120 

prognosis, .... 121 

treatment, .... 121 

Atelectasis pulmonum, or imperfect 

expansion of lungs, . . . 114 

Auscultation of lungs, . . 44,45 



E, 



Bullae, 640 

Bothriocephalus latus, . . . 685 
Brain, Congestion of. See Cerebral 

congestion. 
Brain, Inflammation of membranes 
of. See Meningitis, Simple and 
Tubercular. 
Broad Tape-Worm. See Taenia 
lata. 

Bronchitis, 175 

synonymes, frequency, . 175 

forms, 176 

predisposing causes, . . 176 
exciting causes, . . . 177 



704 



INDEX. 



Bronchitis, anatomical lesions, . 178 
of acute ordinary 

form, . . . 179 
of capillary form, . 179 
presence of dilata- 
tion of bronchia, . 179 
bronchial abscesses, 180 
lesions of chronic 
bronchitis, . 181 
symptoms, .... 182 
of acute simple bronchitis, 182 
of acute suffocative form 

or capillary bronchitis, 183 

of chronic bronchitis, . 185 

particular physical signs, . 187 

particular rational symptoms, 188 

diagnosis, .... 189 

prognosis, .... 191 

treatment, .... 191 

C. 
Cancrum Oris. See Ulcerative sto- 
matitis. 
Carpo-Pedal spasms. See Laryn- 
gismus stridulus. 
Catarrh. See Bronchitis. 

Cerebral congestion, . . . 411 

symptoms, . . . 413 

treatment, .... 414 

hemorrhage, . . . 415 

forms, 415 

causes, .... 416 

anatomical lesions, . . 417 

of apoplexy in cavities, 417 

of meningeal apoplexy, . 417 

symptoms, . . . 420 

of hemorrhage into the 

substance of the brain, 420 

of meningeal hemorrhage, 421 

duration, .... 422 

diagnosis, .... 422 

prognosis, ., 423 

treatment, .... 423 
Child, general appearance of in 

health and in sickness, ... 28 

Cholera infantum, . . . 339 

frequency, .... 340 

causes, .... 340 

anatomical lesions, . . 343 

nature, .... 345 

symptoms, .... 347 



Cholera infantum, duration, . 352 

diagnosis, .... 352 

prognosis, .... 352 

treatment, .... 353 

Chorea, 470 

synonymes, .... 470 

predisposing causes, . . 471 

exciting causes, . . . 471 

anatomical lesions, . . 471 

symptoms, .... 471 

course, .... 474 

duration, .... 474 

nature, » 474 

diagnosis, .... 474 

prognosis, .... 475 

treatment, .... 475 

Collapse of lungs, . . . 123 
Colon, inflammation of. See Entero- 
colitis. 

Contraction with rigidity, . . 459 

causes, .... 460 

nature, 460 

symptoms, . . . 461 

diagnosis 462 

prognosis, .... 462 

treatment, .... 463 

Contracture, .... 459 
Convulsions, General. See Eclamp- 
sia. 
Coryza, definition, synonymes, forms, 

frequency, .... 53 

causes, 54 

anatomical lesions, . . 54 

symptoms, .... 54 

prognosis, .... 57 

treatment, .... 57 
Countenance, diagnostic signs from, 22, 23 

coloration of, . . 23 

Croup-like convulsion, . . . 443 
Croup, Membranous or True. See 
Pseudo-membranous laryngitis. 
Croup, Spasmodic, False, or Catar- 
rhal. See Spasmodic simple la- 
ryngitis. 

Crusta lactea, .... 649 
Cry, the, characters of, 25, 26, 27, 28 
Cutaneous surface, signs from, 31, 32, 33 
Cynanche maligna. See Pseudo- 
membranous pharyngitis. 
Cynanche Tonsillaris. See Simple 
pharyngitis. 





INDEX. 


705 


D. 




Ecthyma, varieties, . 


646 






causes, . 


. 646 


Decubitus of children, 


30 


symptoms, . 


646 


in different diseases, . 30, 31 


diagnosis, 


. 647 


Dejections, signs from, . 


51 


prognosis, . 


647 


Diagnosis, method of, in children, 18, 19 


treatment, 


. 647 


Diarrhoea, inflammatory, bilious, 




Eczema, 


623 


mucous, chronic. See Entero-co- 




frequency, 


. 623 


litis. 




forms, 


623 


Diarrhoea, simple, .... 


294 


causes, . 


. 623 


general remarks, 


294 


symptoms, 


623 


causes, 


295 


diagnosis, 


. 625 


symptoms, 


297 


prognosis, . 


626 


diagnosis, .... 


299 


treatment, 


. 627 


prognosis, .... 


299 


Enteritis, follicular. See Entero- 


treatment, .... 


300 


colitis and cholera infantum. 


Digestive organs, diseases of, 


229 


Entero-colitis, 


312 


Diphtherite. See Pseudo-membra- 




general remarks, 


. 312 


nous pharyngitis. 




frequency, . 


313 


Drinks, manner of taking, as diag- 




forms, . 


. 314 


nostic sign, 


50 


causes, 


314 


Dysentery, 


365 


anatomical lesions 


. 317 


causes, 


365 


symptoms of acute form, . 323 


anatomical lesions, . 


365 


of chronic form, . . 327 


symptoms, .... 


366 


course, 


328 


diagnosis, .... 


366 


duration, 


. 328 


prognosis, .... 


366 


diagnosis, . 


328 


treatment, .... 


367 


prognosis, 


. 328 


Dyspepsia, in infants, 


285 


treatment, 


329 


in older children, 


2S7 


Eruptive fevers, 


. 482 






Erysipelas, . 


607 






frequency, 


. 607 






causes, 


607 






symptoms, . 


. 608 


E. 




duration, . 


610 






diagnosis, 


. 611 






prognosis, . 


611 


Eclampsia, 


425 


treatment, 


. 612 


general remarks, 


425 


Erythema, . 


601 


classifications of, . 


425 


frequency, 


. 601 


synonymes, 


426 


forms, 


601 


frequency, .... 


426 


symptoms, 


. 602 


predisposing causes, . 


426 


diagnosis, . 


604 


exciting causes, 


428 


prognosis, 


. 605 


symptoms, 


428 


treatment, . 


605 


nature, 


432 


Essay, introductory, 


. 17 


diagnosis, .... 


433 


Essera. See Urticaria. 




prognosis, .... 


435 


Examination, clinical, in 


children, 17 


treatment, .... 


436 


difficulties of, . 


17, 18, 19 


Ecthyma, 


646 


Expansion, imperfect, of 1 
Atelectasis. 


ungs. See 



45 



706 



INDEX. 



Fauces, examination of, . 


47 


mode of examining, . 


49 


Favus, 


670 


varieties, .... 


670 


causes, .... 


. 671 


symptoms, 


671 


nature, .... 


673 


diagnosis, .... 


674 


prognosis, 


. 674 


treatment, .... 


674 


Fevers, eruptive, 


482 


Functional diseases of stomach anc 




intestines, 


283 



G. 



Gangrene of the mouth, . . 238 

Gastritis, 304 

general remarks, . . 304 

frequency, .... 305 

causes, .... 305 

anatomical lesions, . . 306 

symptoms, . . . 309 

diagnosis and prognosis, . 310 

treatment, .... 310 
General convulsions. See Eclamp- 
sia. 
Gestures of children, . . 30,31 

Glottis, spasm of the, . . . 443 

Gourme, 649 

Gum, white and red, . . . 664 



H. 



Heart, examination of, . . . 37 

Herpes, 629 

varieties, .... 630 

causes, .... 630 

symptoms, .... 630 

diagnosis, . . . 634 

prognosis, .... 635 

treatment, . . . 635 

Herpes capitis. See Ringworm of 
the scalp. 

Herpes tonsurans. See Ringworm 
of the scalp. 






Hives. See Spasmodic laryngitis. 
and Urticaria. 

Holding-breath spells, . . . 451 

Hooping-cough, .... 211 

frequency, .... 212 

causes, .... 212 

symptoms, .... 212 

complications, . . . 215 

diagnosis, .... 218 

prognosis, . . . 218 

nature, .... 219 

treatment, . . . 220 

Hydrocephalus, acute, . . . 407 
formerly confounded with tu- 
bercular meningitis, 372, 398,407 

causes, 408 

anatomical lesions, . . 408 

symptoms, .... 408 

diagnosis, .... 409 

prognosis, .... 409 

treatment, . . . 409 



I. 



Ichthyosis, 
Impetigo, . 

synonymes, . 

varieties, . 

causes, . 

symptoms, 

diagnosis, 

prognosis, 

treatment, 
Indigestion, 

causes, . 

symptoms, 

diagnosis, 

prognosis, % . 

treatment, 
Inflammation of the lungs. 

Pneumonia. 
Intestines, diseases of, . 

general remarks, 
inflammation of. 



See 



See 



669 
648 
649 
649 
649 
650 
655 
655 
656 
283 
283 
285 
288 
288 
289 



280 
280 



Entero-colitis. 



Itch. See Scabies. 



K. 



Kopp's Asthma, 



443 



INDEX. 



707 



L. 



Laryngitis, pseudo'membranous, 

definition, synonymes, fre 
quency, 

predisposing causes, 

exciting causes, . 

anatomical lesions, 

symptoms, . 

duration, . 

diagnosis, 

prognosis, 

treatment, 
simple, without spasm 

definition, frequency, 

anatomical lesions 

symptoms, . 

duration, . 

diagnosis, 

prognosis, . 

treatment, . 
spasmodic simple, 

definition, frequency, forms 
varieties, . 

predisposing causes 

exciting causes, 

anatomical lesions, 

symptoms, . 

duration, . 

nature of, 

diagnosis, . 

prognosis, 

treatment, 
Laryngismus stridulus, . 

synonymes, 

frequency, . 

predisposing causes 

exciting causes, . 

nature, 

theories of, . 

symptoms, 

duration, 

diagnosis, . 

prognosis, 

treatment, 
Larynx, general remarks on dis 
eases of, 
spasm of, 
Lepra, 
Lichen, 

causes, . 



83 

83 
84 
85 
85 
86 
91 
91 
91 
92 
61 
61 
62 
62 
64 
64 
64 
64 
65 

65 

66 

67 

61 

68 

71 

72 

73 

76 

77 

443 

443 

443 

444 

444 

444 

445 

449 

451 

452 

452 

452 

60 
443 
668 
665 
665 



Lichen, symptoms, . . . 665 
diagnosis, .... 666 
treatment, ... 666 

Lumbrici. See Ascaris lumbri- 

coides. 
Lumbricoides. See Ascaris lum- 

bricoides. 
Lungs and pleura, general remarks 

on diseases of, . . .114 

Lungs, auscultation and percussion 

of, 41,42,43 

Lungs, collapse of, . . . 123 

Lungs, imperfect expansion of. See 

Atelectasis. 
Lungs, inflammation of. See Pneu- 



M. 



Maw-Worm. See Ascaris vermi- 
cularis. 

Measles, 

frequency, 

causes, 

symptoms, 

of the regular form, 
irregularities, 
of malignant cases, . 
complications and sequelae, 
anatomical lesions, . 
diagnosis, .... 
prognosis, .... 
treatment, .... 564 
hygienic, of regular form, 564 
therapeutical, of regular 
form, . 
of the complications 
Melitagra, . 
Meningitis, simple, 
frequency, 
causes, . 

anatomical lesions, 
symptoms, . 
diagnosis, . 
prognosis, 
treatment, . 
tubercular, 
frequency, . 
predisposing causes, 
exciting causes, 
anatomical lesions, 



546 
546 
547 
548 
548 
552 
554 
555 
561 
561 
562 



565 
566 
649 
398 
398 
399 
399 
400 
403 
404 
404 
371 
372 
373 
373 
373 



708 


INDEX. 




Meningitis, tubercular, . 


377 


Pharyngitis, pseudo-membranous, 




symptoms, 


377 


causes, 


271 


duration, . 


384 


anatomical lesions, . 


272 


diagnosis, .... 


384 


symptoms, . . . . 


273 


prognosis, . 


385 


duration, .... 


275 


treatment, .... 


389 


diagnosis, . 


276 


Milk-crust, 


649 


prognosis, ... 


276 


Milky-crust. See Eczema and Im- 




treatment, local, . 


277 


petigo. 




general, 


278 


Mouth, diseases of, . 


229 


simple, 


265 


examination of, ' 


17,48 


synonymes, 


265 


mode of examining, 


49 


causes, 


265 


gangrene of, . 


238 


anatomical lesions, . 


265 


predisposing causes, 


238 


symptoms, . . . . 


266 


exciting causes, . 


239 


diagnosis, .... 


268 


anatomical lesions, 


239 


prognosis, . . . . 


269 


symptoms, . 


240 


treatment, .... 


269 


complications, 


243 


Phlyzacia, 


646 


diagnosis, . 


243 


Pityriasis, 


669 


prognosis, 


245 


Pleurisy, 


197 


treatment, . 


245 


frequency, 


197 






forms, 


197 


N. 




predisposing causes, . 


198 






exciting causes, 


198 


Nervous system, diseases of, 


370 


anatomical lesions, . 


198 


general remarks, . 


370 


symptoms, .... 


199 


Nettle-rash. See Urticaria. 




physical signs, . 


199 






rational symptoms, 


202 






symptoms of chronic pleurisy, 


204 


0. 




diagnosis, .... 


205 






prognosis, .... 


206 


Oxyuris vermicularis. See Ascaris 




treatment, .... 


207 


vermicularis. 




Pneumonia, 


139 






frequency of, . 


139 


P. 




forms of, .... 
lobular form of, often con- 


140 


Pain, its effects on the expression, 


23 


founded with bronchitis, 


140 


Pemphigus, .... 


640 


predisposing causes, 


141 


frequency, . . . . 


640 


exciting causes, 


142 


causes, .... 


640 


anatomical lesions of lobar 




symptoms, . 


640 


form, .... 


142 


diagnosis, .... 


641 


of partial form, . 


144 


prognosis, . 


641 


of congestion of the lung, 


145 


treatment, .... 


642 


symptoms of, in new-born 




gangrenosus, . 


643 


and suckling children, 


148 


infantilis, .... 


643 


of lobar form in children 




Papules, 


663 


over two years of age, 


152 


Percussion, characters of, . 


45 


of partial form, . 


156 


Pertussis. See Hooping-Cough. 




particular physical signs of, . 


157 


Pharyngitis, pseudo-membranous, . 


271 


particular rational symptoms, 


159 


synonymes, 


271 


diagnosis. .... 


161 





INDEX. 


709 


Pneumonia, prognosis, . 


164 


Round-worm. See Ascaris lumbri- 




treatment, 


165 


coides. 




Pompholyx. See Pemphigus. 




Rupia, 


642 


Porrigo scutulata. See Ringworm 




varieties, . 


643 


of the scalp. 




causes, 


643 


Porrigo. See Favus. 




symptoms, 


643 


Porrigo furfuracea. See Ringworm 




diagnosis, .... 


644 


of the scalp. 




prognosis, 


645 


Prickly heat, 


665 


treatment, .... 


645 


Prurigo 


666 


Rubeola. See Measles. 




causes, 


667 






symptoms, 


66? 






diagnosis and prognosis, 


667 


S. 




treatment, 


667 






Psora. See Scabies. 




Scabies, 


636 


Psoriasis, 


668 


frequency, 


636 


varieties, .... 


668 


causes, 


636 


symptoms, .... 


668 


symptoms, 


637 


treatment, 


669 


diagnosis, .... 


638 


Psydracia, 


649 


prognosis, .... 


639 


Pulse, in children, . . 34,3 


5, 36 


treatment, .... 


639 


rate of, 


34 


Scald head. See Eczema and Im- 




intermittence or irregularity of, 


36 


petigo. 




irritability of, ... 


36 


Scall, 


649 


to be examined during sleep, . 


37 


Scarlatina. See Scarlet fever. 




Pustules, 


646 


Scarlet fever, .... 


482 


Putrid Sore-Throat. See Pseudo- 




frequency, 


4S2 


membranous pharyngitis. 




forms, 


483 






causes, .... 


485 






symptoms, .... 


487 


R. 




of mild cases, 


4SS 






of grave cases, 


492 


Rashes, 


601 


dropsy in, ... 


508 


Respiration, its rate and general 




anatomical lesions, 


514 


characters, . . . .38, 39, 40 


diagnosis, .... 


515 


Respiratory sounds, character of, . 


44 


prognosis, .... 


516 


Revaccination, .... 


595 


treatment. 


519 


Ringworm. See Herpes. 




hygienic, 


519 


Ringworm of the scalp, . 


678 


of mild cases, 


520 


causes, .... 


678 


of grave cases, 


523 


symptoms, .... 


679 


of the angina, 


541 


nature, .... 


680 


of dropsy, 


543 


diagnosis and prognosis, 


680 


prophylactic, 


544 


treatment, 


680 


Scarlet rash. See Roseola. 




Roseola, 


615 


Seat worm. See Ascaris vermicu- 




frequency and forms, 


615 


laris. 




causes, 


615 


Simple meningitis. See Menin- 




symptoms, 


616 


gitis. 




diagnosis, .... 


617 


Skin, color of, in infants, . . 32, 33 


prognosis, .... 


618 


Skin, diseases of, . 


601 


treatment, .... 


618 


introductory remarks, 


601 



710 



INDEX. 



Sleep, diagnostic signs from, . 24 
Small-pox, 

frequency, 

forms, 

causes, .... 

symptoms, of the regular 
form, .... 
of the irregular varieties, 
of varioloid, . 

complications, . 

anatomical lesions, 

diagnosis, .... 

prognosis, .... 

treatment, 

of the complications, 
Snuffles, 

morbid, .... 

Spasm of the glottis, . 
Spasm of the larynx, 

Squamae, 

Stomach and intestines, diseases of, 

general remarks, 
Stomach, inflammation of. See 

Gastritis. 
Stomach, softening of, . . 304, 
Stomatitis, simple or erythematous, 

causes, .... 

symptoms, 

treatment,. .... 

ulcerative, or ulcero-membra- 

nous, .... 

synonymes, 

frequency, 

predisposing causes, 

exciting causes, 

symptoms, 

diagnosis and prognosis, 

treatment, 
Strophulus, .... 

varieties and symptoms, 

diagnosis. 

prognosis, . 

treatment, .... 
Summer-complaint. See Cholera 
infantum. 



T. 



,25 
570 
570 
570 
570 

571 
577 
578 
579 
579 
580 
581 
5S2 
583 
53 
53 
443 
443 
668 
280 
280 



305 
229 
229 
230 

230 

233 
233 
233 
233 
234 
234 
235 
236 
663 
664 
664 
664 
664 



Taenia lata, 

description of, 



685 

6S5 



See Rin< 



Taenia solium, 

description, 
Threadworm. See Ascaris vermi 

cularis. 
Throat, diseases of the, . 
Thymic asthma, 

Tinea. See Impetigo and Favus. 
Tinea lactea, 

Tracheotomy, .... 
condemned by English wri 

ters, .... 
recommended by French wri 

ters, ... 104 

whether dangerous in itself 

or not, 
when to be performed, 
operation, 
modifications in operation, by 
M. Trousseau 
Trichiasis "furfuracea. 
worm of the scalp. 
Tricocephalus dispar, 

description of, . 
Thrush, .... 
synonymes, 
frequency, 
forms, 

predisposing causes, 
exciting causes, 
anatomical lesions, 
symptoms, 
nature, . 
diagnosis, . 
prognosis, 
treatment, 
Tonsillitis. See Simple pharyngitis 
Tonsils, inflammation of. See Sim 

pie pharyngitis. 
Tooth-rash. See Eczema and Im 

petigo. 
Tubercular meningitis. See Me 
ningitis. 



U. 

Ulceration of the Mouth. See Ul- 
cerative stomatitis. 

Urticaria, 

forms and frequency, 
causes, 



. 684 


684 


. 249 


250 


. 250 


250 


. 250 


252 


. 252 


. ' 253 


. 258 


259 


. 259 


259 



685 

265 
443 

649 
103 

104 

105 

108 
110 
112 



619 
619 
619 



INDEX. 



711 



620 
621 
621 
621 



Urticaria, symptoms, 
diagnosis, 
prognosis, . 
treatment, 



V. 



Vaccination, 594 

Vaccine disease, .... 587 

synonymes, .... 587 

history, .... 587 

symptoms, .... 587 

irregularities and anomalies, 590 

diagnosis, .... 591 

protective power, . . 592 

susceptibility to, . . . 593 



Varicella, 597 

causes, 598 

symptoms, . . . 59S 

diagnosis, .... 600 

prognosis, .... 600 
treatment, . . . .600 
Variola. See Small-pox. 

Varioloid, 578 

Vesicles, 623 

Vomiting, diagnostic signs from, 50, 51 

W. 

Water on the Brain. See Tubercu- 
lar meningitis. 

Worms, 683 

general remarks upon, . 683 



THE END. 



£269 



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